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November 20, 2014 Thursday
Late Edition - Final
More Clarity on Health Care
BYLINE: By ROBB MANDELBAUM
SECTION: Section B; Column 0; Business/Financial Desk; YOU'RE THE BOSS; Pg. 9
LENGTH: 970 words
Since the implementation of the Affordable Care Act, many small businesses have been intrigued by the possibility that they might be able to stop dealing with health insurance entirely and instead offer their employees a stipend to go buy insurance on the individual exchanges. But in a clarification issued in early November, the federal government appears to have taken a stand against that strategy.
There had been little doubt among most lawyers who follow the tax implications of the Affordable Care Act that a company would not be able to subsidize its employees' individual health insurance with pretax dollars (the way that premiums for group health insurance are excluded from an employee's income). But as we reported a few weeks ago, the government's guidance on using post-tax compensation was murkier. With its recent statement, the government removed some -- though not all -- of that ambiguity.
The additional clarity came in the form of a ''frequently asked questions'' document issued by the Department of Labor. Even now, however, the issues remain complex and open to interpretation, and the tax and benefits lawyers contacted by You're the Boss offered differing perspectives on the Labor Department's answers. What better way to try to make sense of these issues than to borrow a trope from the government and present them in the form of an FAQ.
Q.
So, can a company reimburse workers for their insurance premiums with after-tax money?
A.
No. Any reimbursement scheme constitutes a group health plan, according to the Labor Department. This designation is important, because the government had already decided that a group health plan must comply with certain market reforms in the Affordable Care Act, including one that bans dollar limits for certain benefits. And a plan that reimburses members for individual policies simply cannot comply with those requirements, according to the agencies.
Businesses with plans that violate the health law's market rules can face penalties of up to $36,500 a year for each affected employee.
Up until now, there had been a debate among lawyers about whether a company could expressly reimburse individual insurance premiums with taxable income, or, if not, condition the additional compensation on buying insurance -- even if the money is not tied directly to the cost of premiums. But the latest advice from the Labor Department should end those arguments, according to four of five lawyers contacted by You're the Boss.
''What we know now is that you can't condition the receipt of after-tax money only on the purchase of insurance,'' said Christopher E. Condeluci, a Washington-based lawyer. ''Instead, you have to give the employee the choice between taking the money as cash wages or allocating that money toward the purchase of insurance.''
The one lawyer we talked to who disagreed is Seth Perretta, who represents a number of large business organizations with a stake in the various rule-makings of the Affordable Care Act. ''I can condition employment on all sorts of things,'' Mr. Perretta said. ''I can condition a subset of compensation on all sorts of things, on the employee doing lawful acts. I think it really turns on whether the regulators would agree that so long as the amount I'm paying to you is not directly related to the amount you pay for insurance, whether or not disconnecting the two would allow me to treat that as a taxable wage.'' Even Mr. Perretta said the answer was still not clear.
Q.
Suppose an owner just gives raises and doesn't specifically reimburse premiums? Can the owner tailor the amount of additional compensation for each person to the cost of health insurance without crossing the line into reimbursement?
A.
Yes, at least if the owner gives the raise unconditionally. (Mr. Perretta said it was unclear whether correlating a conditional raise would be permissible because ''we are in uncharted territory.'') For example, the raises could follow the government's age curve that sets the relative cost for premiums in the individual market. ''Employee pay rates and raises are subject to various employment non-discrimination rules but, other than that, employers have wide discretion in setting pay,'' said Linda Mendel, a lawyer in Columbus, Ohio. It is not illegal, by the way, to discriminate in favor of older workers.
Q.
What about Zane Benefits, which is promoting a plan it says allows companies to reimburse employees who buy individual insurance with pre-tax dollars -- and even lets lower paid employees who qualify claim federal subsidies when they buy their insurance on the exchanges. How is this possible?
A.
It is not, at least according to federal regulators. The recent guidance did not mention Zane by name, but it referred to the type of plan it uses (a Section 105 plan, after that section of the tax code) and said that it, like other reimbursement plans, was subject to the Affordable Care Act's insurance market reforms but cannot comply with them because of the reimbursement mechanism. Moreover, the Labor Department declared, ''employees participating in such arrangements are ineligible for premium tax credits (or cost-sharing reductions) for Marketplace coverage.''
Zane, for its part, published its own FAQ in response to the Department of Labor FAQ. In it, Zane insisted that its plan complies with the health law and that businesses that use it can rest assured that their employees can qualify for exchange subsidies. ''This is nothing new,'' Rick Lindquist, Zane's president, wrote in an email about the Labor Department's guidance.
All of the lawyers we've talked to disagree with Zane's legal reasoning, but until one side or the other forces a resolution of the issue, it will be Zane's word against the government's.
This is a more complete version of the story than the one that appeared in print.
URL: http://boss.blogs.nytimes.com/2014/11/18/regulators-warn-against-reimbursing-employees-for-health-premiums/
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The New York Times
January 2, 2017 Monday 00:00 EST
After Obama, Some Health Reforms May Prove Lasting
BYLINE: ABBY GOODNOUGH and ROBERT PEAR
SECTION: US; politics
LENGTH: 3523 words
HIGHLIGHT: A transformation of the delivery of health care may be an enduring legacy for the president, even as Republicans plan to repeal the Affordable Care Act.
FISHERS, Ind. - Fragments of bone and cartilage arced across the operating room as Dr. R. Michael Meneghini drilled into the knee of his first patient at a hospital here at dawn. Within an hour, the 66-year-old woman had a replacement joint made of titanium and cobalt chrome, and she was sent home the next day.
But the Obama administration was watching over her caregivers' shoulders. If, over three months, her medical costs exceeded a target amount set by President Obama's health regulators in Washington, Dr. Meneghini's employer, Indiana University Health, stood to lose money.
Such efforts to squeeze spending out of the nation's health system may well remain as Mr. Obama exits the West Wing and Donald J. Trump takes his seat in the Oval Office. The Affordable Care Act is in extreme peril, and Mr. Obama will meet with congressional Democrats at the Capitol on Wednesday to try to devise a strategy that can stave off the quick-strike repeal of the health law that Republicans plan for the opening months of the Trump administration.
But the transformation of American health care that has occurred over the last eight years - touching every aspect of the system, down to a knee replacement in the nation's heartland - has a momentum that could prove impossible to stop.
Expanding insurance coverage to more than 20 million Americans is among Mr. Obama's proudest accomplishments, but the changes he has pushed go deeper. They have had an impact on every level of care - from what happens during checkups and surgery to how doctors and hospitals are paid, how their results are measured and how they work together.
"From the moment I first set foot in the Oval Office in February 2009, the president told me that the law can't be just about covering the uninsured, but that it also has to be about changing the way care is delivered," said Nancy-Ann DeParle, who as a White House aide helped lead the effort to pass and carry out the health law. His message, she said: "I don't want to cover everyone and just put them in the same creaky old delivery system."
Changes in the delivery system already affect far more people than the law's higher-profile coverage gains. To visit IU Health, the largest health care provider in Indiana, with 15 hospitals and 8,700 doctors, is to see those changes up close. Its leaders have started moving away from fee-for-service medicine, where every procedure, examination and prescription fetches a price. The emphasis now is on preventive care, on taking responsibility for the health of patients not only in the hospital, but also in the community.
Social work has become a larger part of the medical mission. Collaboration between doctors is becoming a necessity.
"I don't know who could be against it: higher quality and lower cost," said Ryan C. Kitchell, an executive vice president and the chief administrative officer of IU Health.
And unlike Mr. Obama's insurance coverage expansions, these changes are not in jeopardy, said Dennis M. Murphy, IU Health's president and chief executive.
"We've got to create more value in health care," Mr. Murphy said in an interview after Mr. Trump's election. "That principle, I think, survives."
During Mr. Obama's tenure, big systems like IU Health have gobbled up smaller hospitals and physician groups as the industry has consolidated, partly in response to incentives in the Affordable Care Act. Most doctors across the United States are using electronic medical records, installed in many cases with federal money provided by the economic stimulus law of 2009. The federal government and private insurers are rewarding health care providers that work together to coordinate care and avoid unnecessary expenses.
Doctors and hospitals here are obsessed with metrics, not least because under the health law, they may be rewarded or penalized based on their performance. They tally the number of medication errors, the number of patients injured in falls and the number who develop infections after certain types of surgery.
Expanding coverage is seen not as a political issue, but as a clinical and financial imperative. IU Health has more than 150 "navigators" who work with patients to help them get insurance, often through a Medicaid expansion authorized and funded by the health law and engineered here by Gov. Mike Pence, the vice president-elect.
"I've been a registered Republican my whole life, but I support the Affordable Care Act," said Dr. Gregory C. Kiray, co-chief of primary care for IU Health Physicians, "because it allows patients to be taken care of."
To better understand how Mr. Obama has changed health care, two reporters from The New York Times spent a week shadowing and talking to doctors, patients, executives and others at IU Health, a system that demonstrates the breadth of changes catalyzed by the Affordable Care Act.
To many IU Health employees, the pace of change can be bewildering, the new directives too numerous or burdensome.
"People feel like they are swimming in an ocean, drowning," said Dr. Meneghini, an orthopedic surgeon at IU Health's Saxony Hospital here in Fishers, a suburb of Indianapolis.
But the medical profession increasingly understands that painful as it is, the revolution is necessary and unstoppable.
"The national economy cannot sustain health care being as big a share of the gross domestic product as it is," Mr. Murphy said, uttering what once amounted to heresy for a health care provider.
'Be Thoughtfully Aggressive'
Fury over the Affordable Care Act helped jump-start the Tea Party movement and sweep Republicans into control of the House of Representatives in 2010 and the Senate in 2014. It ensured gridlock that stifled many of Mr. Obama's greatest legislative ambitions for six of his eight years in office, and it may well have played a role in the election of Mr. Trump, who attacked the law throughout his campaign.
Yet to Mr. Obama, the law remains one of his greatest achievements, said Denis McDonough, the White House chief of staff. It also has been his constant concern.
"This attention to cost and concern about cost, and even the emotional concern about cost, comes up all the time," Mr. McDonough said.
The Affordable Care Act gave the government sweeping authority to test new models of care, and the administration has aggressively used that power to try different ways of paying for cancer care, heart surgery, primary care and other services covered by Medicare and Medicaid.
Sylvia Mathews Burwell, who has been the secretary of health and human services since 2014, said she met with Mr. Obama early in her tenure to describe a series of payment and delivery reforms. He was so supportive, she said, that she and her team decided to undertake even more changes.
The size and speed of some of those initiatives have provoked criticism from Republicans, including Representative Tom Price of Georgia, picked by Mr. Trump to be the health and human services secretary. They say the efforts threaten the quality of care and exceed the authority of the agency overseeing Medicare by requiring doctors and hospitals to participate.
More than 170 House Republicans signed a recent letter of which Mr. Price was an author, urging the administration to "stop experimenting with Americans' health."
But moving aggressively to change how medical care is delivered and paid for has been important to Mr. Obama. In 2015, his administration set a goal for half of all Medicare payments to be tied to the quality, instead of the quantity, of care that doctors and hospitals provide by 2018. Mr. Obama believes that basing pay on whether a doctor visit or a medical procedure helps a patient, rather than on how much care the patient receives, will result in better care.
"What he said was, 'Be thoughtfully aggressive,'" Ms. Burwell said.
At Patients' Service and Mercy
"I started drinking soda again," confessed Willie Johnson, a 52-year-old patient with uncontrolled diabetes and high blood pressure.
"How much?" Dr. Michael E. Busha, a primary care physician at IU Health in Indianapolis, asked quietly as he updated Mr. Johnson's electronic record.
"Quite a bit."
For Dr. Busha, that mattered.
He helps lead the IU system's effort to measure how well doctors do at keeping patients healthy. And even this champion of "quality measures" - vital to the Obama administration's goal of paying doctors based on outcomes, not the amount of care - has found that it is not always easy to meet them.
If enough of his patients fall below the standards set by IU Health, Dr. Busha could lose some of his income. The average salary for the system's primary care doctors is $236,000. Of that, $50,000 is tied to meeting benchmarks for quality, access (whether a doctor agrees to see patients on weekends and at night, for example) and other performance measures.
Mr. Johnson, who registers patients when they arrive for neurology appointments at IU Health Methodist Hospital in Indianapolis, was not helping. He also had stopped taking his cholesterol medicine because it left a bad taste in his mouth. And he was using neither the gym membership that IU Health helps pay for nor his sleep apnea machine. "I never could get adjusted to it," he told the doctor.
Like other primary care doctors at IU Health, Dr. Busha is part of a team that includes a pharmacist, a social worker and a "care manager." Such teams, encouraged by the health law, focus on patients like Mr. Johnson who are not meeting IU Health's quality measures, and who are disproportionately likely to end up in the emergency room or be hospitalized.
"The whole paradigm now is to identify your high-risk people and provide more resources to them, provide better care to them, keep them out of the hospital," said Dr. Kiray, the primary care co-chief.
Partly because of these efforts, IU Health's two adult hospitals in downtown Indianapolis are already seeing 12 percent fewer inpatients than they were in 2013. The system is merging the two hospitals into a $1 billion medical center focused heavily on outpatient care.
President Obama would be proud. Administration officials have continually emphasized the importance of primary care and the "social determinants" of health. They have offered grants to health care providers to identify Medicaid and Medicare patients with unmet social needs: inadequate food supplies, unpaid rent or utility bills and experience with violence at home, for example.
But with some patients, only so much can be done: Mr. Johnson's care manager had stopped working with him after deciding he was not ready to make changes.
"Are we ready to try it again?" Dr. Busha asked him.
Mr. Johnson agreed to let the care manager contact him, and to return for a follow-up visit in two months.
Such efforts, said Mr. Murphy, the system's chief executive, will remain "highly relevant" even if the Affordable Care Act is repealed.
The push toward a "risk-based" model over traditional fee-for-service medicine has spread beyond Medicare and Medicaid to private insurers. And the Obama administration has been testing new ways to save money on all sorts of medical care. Some of the experiments, overseen by an office created under the Affordable Care Act, have shown promise. But evaluating results is difficult.
"It may be good in theory," Dr. John M. Thomas, a primary care physician at an IU Health practice in Lafayette, said of Dr. Busha's system of quality measurements. "But there are a lot of flaws."
For example, he explained, rather than risk being paid less because some patients have uncontrolled diabetes, doctors could tell those patients, "I'm sorry, you're not in compliance with your medications, and I don't want to be your physician."
Dr. Busha said he was used to hearing such arguments.
"I have that conversation on a weekly basis," he said. "You know: 'What if my patients don't believe in immunizations? Why am I held accountable for that?'"
He added, "We kind of tell them, 'It's your job to convince them.'"
Suddenly, Cost Counts
When IU Health discovered that a knee surgeon was using "bone cement" costing $300 a patient while another achieved the same results for $84, the first doctor was promptly informed. He switched.
IU Health now posts a color-coded "value tracker" in operating rooms that gives a green light to lower-cost surgical products, a red light to high-cost items and a yellow light to those in between.
"A huge cultural shift," Dr. Anthony T. Sorkin, the medical director of orthopedics, said of the changes in his department - for the surgeons and the patients.
The IU Health system performed 3,900 hip- and knee-replacement operations in the year that ended on June 30. But it is not enough for doctors just to replace a knee or a hip. They are under pressure, from Medicare and private insurers, to manage and coordinate care for their patients before and after surgery. And, they say, payment for their services is continually being squeezed.
Doctors have three main ways to cut costs: improve the condition of patients before surgery, look for savings in every item used in the operating room (gloves, gowns, syringes, surgical tools, sutures, sponges and the implant itself), and send patients to nursing homes that strive to shorten the length of stay.
"I've been an orthopedic surgeon for 18 years," Dr. Sorkin said. "For many of those years, I never once considered the cost for nursing homes."
Why such attention to cost? In 67 geographic areas, including Indianapolis, Medicare now sets a target price for joint-replacement procedures. That target covers not only doctor services and hospital care but also 90 days of follow-up services like physical therapy, home health care and nursing-home stays. Hospitals are at risk: Medicare can pay bonuses or impose penalties, depending on whether spending targets and quality standards set by the government are met.
"We worry about 90 days of care, 90 days of Medicare spending, not just the brief time a patient spends in the hospital," Dr. Sorkin said.
The joint-replacement program was one of the main targets of the letter that Mr. Price and other Republicans wrote to the Obama administration in September, complaining that such programs should be tested on a "voluntary, limited-scale basis" with no requirement for doctors to participate.
But in Indianapolis, the results have been promising. By working closely with nursing homes, IU Health halved the length of stay for patients recuperating from surgery, to an average of 12 days from 24 days in early 2016.
Doctors and nurses understand the need for change, but some still have concerns.
"These reforms are all intended to slow down the consumption of health care resources in the United States," said Dr. Meneghini, who is the director of joint-replacement at Saxony Hospital here in Fishers. "We are careening at a rapid rate to a two-tier system. The public who can't afford it goes to a public hospital and gets free health care. Those who have money get to pay for really nice care."
A Mind Unchanged
Justin Kloski learned that he qualified for Medicaid under the worst of circumstances. The student and part-time lawn-company worker had lost 20 pounds, could not shake a nagging cough and was sleeping 14 hours a day when he decided to visit a clinic in Muncie, Ind., that provides free care for the poor and uninsured. A clinic employee invited Mr. Kloski, now 28, to apply for Medicaid.
A few days later, he took his new coverage to the emergency room at IU Health Ball Memorial Hospital in Muncie. A CT scan found a 15-centimeter tumor in his chest, so big it was pressing on his windpipe. In May 2015, he learned he had Hodgkin's lymphoma, a form of cancer that is curable if caught early.
The Affordable Care Act, and Governor Pence's decision to go against many other Republican governors and expand Medicaid under the law, may well have saved Mr. Kloski's life.
He is among more than 400,000 Indiana residents - many of them previously uninsured - who have enrolled in Medicaid since Mr. Pence expanded it in 2015, the 10th Republican governor to do so. Under the terms of the health law, anyone with income up to 138 percent of the poverty level, or approximately $16,500 a year for an individual, now qualifies in states that opt to expand the program.
IU Health says it receives more Medicaid payments than any other health care provider in the state. Since the expansion began, the percentage of patients with Medicaid has grown to 23.2 from 20.7.
At the same time, the percentage of IU Health patients who are uninsured has fallen to 2.2 from 5.
In 2015 alone, the health system enrolled 14,000 people in Medicaid or private coverage, sometimes even signing up patients as they lay in hospital beds.
"We went all in because it's a pretty big deal to us," said Jonathan W. Vanator, IU Health's vice president for revenue cycle services.
In the first nine months of last year, IU Health officials said, the amount of bad debt owed by patients and referred to collection agencies totaled $233 million, a 23 percent reduction from the comparable period in 2015, thanks largely to Mr. Obama's health law.
But, the officials added, these gains have been largely offset by cuts in Medicare reimbursements and other federal funds under a law that has given and taken away.
Mr. Murphy is among many hospital executives now anxious about the possibility of seeing a bump in uninsured patients if the health law is repealed, while not getting back the federal funds they gave up under the health law. "I do think it would be problematic if part of the deal was changed and not the whole deal," he said.
Mr. Pence expanded Medicaid only after the Obama administration agreed to let Indiana do it in its own way: Instead of getting virtually free coverage, as Medicaid recipients in many other states do, people enrolled in Indiana's expansion pay up to 5 percent of their income toward it. Mr. Trump appears interested in promoting Indiana's "personal responsibility" model: He has picked its chief architect, Seema Verma, to run the Centers for Medicare and Medicaid Services.
Since Mr. Kloski had no income when he enrolled, he paid $1 a month; he has since been classified as "medically frail" and does not have to pay anything.
Medicaid has paid for virtually all of his cancer care, including a one-week hospitalization after the diagnosis, months of chemotherapy, and frequent scans and blood tests.
But Mr. Kloski and his mother, Renee Epperson, are still not fans of the health law over all. They believed that it required that Mr. Kloski be dropped, when he turned 26, from the health plan his mother has through her job at Target - not understanding that it was the law that kept him on the plan until he was 26.
Mr. Kloski paid a penalty for going uninsured in 2014 rather than even explore whether he might qualify for a subsidy and find an affordable private plan through the marketplaces.
"There were so many horror stories about how expensive it was going to be," Ms. Epperson, 47, recalled. "Justin said, 'I'm not even going to try it, Mom.'"
And until they were interviewed for this article, the mother and son did not know that the law was responsible for the expansion of Medicaid that Mr. Kloski benefited from. Neither voted in last year's presidential election; Ms. Epperson said that she disliked both candidates, and that even though Hillary Clinton supported the Affordable Care Act, she found Mrs. Clinton's positions unacceptable on too many other issues, like abortion rights, to support her.
Still, she said, she ardently hopes that Mr. Trump and the Republican Congress will continue allowing low-income adults like her son to qualify for Medicaid.
"Oh my God, yes," she said. "Absolutely."
As for Mr. Murphy, IU Health's chief executive, he said that while he did not want to think too much about changes that were still hypothetical, the prospect of losing the Medicaid expansion made him anxious.
"I worry about lots of things," he said. "That list is probably 50 long, and this is definitely on that list."
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
Gardiner Harris contributed reporting.
PHOTOS: President Obama at the White House after signing the Affordable Care Act into law in March 2010. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES) (A12); At right, Dr. R. Michael Meneghini, left, performing a partial knee replacement at a hospital in the Indiana University Health system. (A12-A13); Lindsay Ehrgott is trained to help patients at IU Health Methodist Hospital sign up for health care if they are not already covered.; Justin Kloski, who has Hodgkin's lymphoma, showing the port on his chest for treatments. Medicaid has paid for virtually all of his cancer care. (PHOTOGRAPHS BY ILANA PANICH-LINSMAN FOR THE NEW YORK TIMES); Protesters gathered in Washington in anticipation of a United States Supreme Court ruling on the health care overhaul law in June 2012. (PHOTOGRAPH BY BRENDAN HOFFMAN FOR THE NEW YORK TIMES) (A13)
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HIGHLIGHT: Richard Mourdock preacts to the Supreme Court's health care ruling.
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Richard Mourdock, the Tea Party favorite who defeated Senator Richard Lugar of Indiana in the Republican primary in May, is fine-tuning another "pre" category, the "preaction."
Mr. Mourdock taped responses to several possible outcomes of the Supreme Court ruling on the constitutionality of the Affordable Care Act - the court upholds the law, the court overturns it, the court splits, the court doesn't provide an answer.
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(Mourdock loses) Indiana just dodged a bullet, and so did the United States Senate.
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June 26, 2015 Friday
Late Edition - Final
Ruling Elicits Sighs of Relief and Vows to Continue Fighting
BYLINE: By ABBY GOODNOUGH and SABRINA TAVERNISE; Jonathan Weisman and Jackie Calmes contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 938 words
WASHINGTON -- Democrats said it was finally time to accept that the Affordable Care Act was here to stay. Republicans vowed to keep trying to get rid of the law, but conceded that at this point, their best chance would be by winning back the White House next year.
And people like Margaret McElwain, who has breast cancer and a part-time job at Target, exulted over the Supreme Court's decision to allow health insurance subsidies to keep flowing to more than six million Americans in the 34 states that did not establish their own online insurance marketplaces under the law.
''Thank God,'' said Ms. McElwain, 64, of Mooresville, N.C., who was on her way to a chemotherapy appointment when she heard about the ruling. She said she pays $96 a month for the Blue Cross Blue Shield plan that she bought through the federal insurance marketplace, and receives a subsidy of more than $700 to cover the rest. ''I really did not know how it was going to turn out, and you cannot imagine my relief.''
Hospitals and health centers across the country were breathing a sigh of relief.
''A catastrophe just got stopped,'' said Dr. Gary Wiltz, an internist who runs a network of community health centers in rural Louisiana. He said his clinics have been able to increase diagnosis and treatment of diabetes and hypertension, two chronic illnesses that hit particularly hard among low-income Americans. ''We have people in the middle of cancer treatments, some being worked up for heart disease. If that insurance would have gone away, it would literally have been a path to early death.''
In Congress, the court's decision left Republicans badly divided on their next move. If the court had sided with the plaintiffs, they had hoped to force President Obama to negotiate a new set of health care reforms more to their liking. Now, any significant legislation will simply be vetoed, they conceded. That leaves them with a decision: Try to do something modest that could overcome a veto, or press forward with an attempt to truly replace the Affordable Care Act?
House Republicans vowed to press forward. But Senate Republican leaders did not appear to share their House colleagues' enthusiasm for continuing to go after the health care law.
''We know the president's not likely to sign anything we send him, and the Democrats are not likely to vote for anything we send him,'' Senator Mitch McConnell, the majority leader, said in an interview. ''So it leaves only one vehicle available, if you want to revisit Obamacare, and that would be to use reconciliation. But no decision has been made on the timing of that.''
Mr. McConnell was referring to an obscure budget rule under which Republicans could make changes to the Affordable Care Act that cannot be filibustered in the Senate -- but only if the changes were about spending and revenue provisions.
In truth, many Republican elected officials were likely relieved, despite their stated opposition to the law, to not have to deal with the fallout of a ruling that would have stripped more than 6.3 million people of subsidized health insurance. Many of those who stood to lose subsidies -- and likely their insurance, which would have proved unaffordable without them -- are Southern working-class whites, on whom Republicans tend to rely for support. About 61 percent of the people who would have become uninsured are white, according to an Urban Institute analysis in January, and about 62 percent live in the South.
Most Republican governors reaffirmed their opposition to the health care law in statements reacting to the decision. But a handful, including Gov. Bill Haslam of Tennessee, had something positive to say. Mr. Haslam tried to expand Medicaid under the health law this year but was rebuffed by his fellow Republicans in the state legislature.
''I am pleased for those folks who have insurance subsidies,'' Mr. Haslam said of the ruling. ''While philosophically I didn't agree with their ruling, in terms of the smoothness of the market and people obtaining coverage in a predictable way, I think that's a good thing.''
More typical was the response from Gov. John Kasich of Ohio, a likely Republican presidential candidate.
''The law has driven up Ohio's health insurance costs significantly,'' he said, ''and I remain convinced that Congress should repeal it and replace it with something that actually reduces costs.''
Polls suggest that Americans remain sharply divided in their opinion of the law, and for some, like Kevin Archer of Tampa, Fla., who gets health insurance through his job selling advertising for newspapers, the ruling was a disappointment.
''I'm very much against it,'' he said of the law. ''It's negative for the country. I don't have the freedom not to buy health care.''
Hospital executives in the 34 states that rely on the federal marketplace, many of who saw drops in uncompensated care costs because of the Affordable Care Act, were among those expressing relief.
''It just sort of creates this huge safety net for all of us, knowing that, when patients come in, there will still be some reimbursement,'' said Meri Armor, the chief executive officer of Le Bonheur Children's Hospital in Memphis.
Also excited was Jimmy Lewis, a 44-year-old concession stand worker in Jackson, Miss. Mr. Lewis said he paid $35 a month for his midlevel silver plan and a subsidy covered the rest. He said he is generally healthy, but has back and tooth problems and is relieved he will still be able to afford his insurance.
''Great, that's great,'' Mr. Lewis said. ''I can't believe it! I really didn't think it was going to hold.''
URL: http://www.nytimes.com/2015/06/26/us/politics/health-law-ruling-elicits-sighs-of-relief-and-vows-to-continue-fighting.html
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April 13, 2012 Friday
Late Edition - Final
Cuomo Acts To Advance Health Law In New York
BYLINE: By THOMAS KAPLAN
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 23
LENGTH: 956 words
ALBANY -- Gov. Andrew M. Cuomo, stepping into the national debate over President Obama's health care law, used his executive power on Thursday to carry out one of its critical features in New York after the state's Republican lawmakers blocked legislation to do so.
Mr. Cuomo, a Democrat who has generally avoided national politics even as he is often mentioned as a potential candidate for president, offered an enthusiastic endorsement of the benefits of the health care measure, which is currently being litigated before the Supreme Court and contested in this year's presidential campaign.
As he issued an executive order to establish a health insurance exchange, an online marketplace where individuals and small businesses can choose among competing health insurance plans, Mr. Cuomo said it would drive down the cost of insurance while helping the 2.7 million uninsured New Yorkers get affordable coverage.
''The bottom line,'' Mr. Cuomo said in a statement, ''is that creating this health exchange will lower the cost of health insurance for small businesses, local governments and individual New Yorkers across the state.''
For nearly a year, Mr. Cuomo asked the Legislature to set up the exchange. But the Republican majority in the State Senate refused to consider the measure, arguing that approving the exchange would amount to condoning the law, the Affordable Care Act, which they deride as Obamacare.
The Senate Republicans also cited the uncertainty surrounding the health care law, given the Supreme Court challenge, and last month, they blocked Mr. Cuomo from including the exchange in the state budget for the fiscal year that began April 1.
The health care law requires each state to put an insurance exchange in place by 2014, and gives the federal government the power to do so in states that do not act on their own.
Mr. Cuomo, unable to win support for the exchange in the State Senate, vowed to move ahead unilaterally, and on Thursday, he signed the order to set up the exchange within the State Health Department, rather than as a separate state entity, as his original legislation had sought to do.
Mr. Cuomo's order drew praise on Thursday from Democratic lawmakers, health advocacy groups and leaders in the state's health care industry. Kenneth E. Raske, the president of the Greater New York Hospital Association, called the move ''a way of alleviating the current crisis facing those that don't have access to care because of lack of insurance.''
But Mr. Cuomo's move irked some conservatives, who are determined to fight the health care law and view state capitals as important battlegrounds in which the law's implementation can be contested.
State Senator Gregory R. Ball, Republican of Putnam County, who has been one of the most vocal critics of the health exchange proposal, said Mr. Cuomo was acting prematurely, given the Supreme Court case. Mr. Ball also criticized the governor for ''sidestepping the Legislature'' to set up the exchange.
''Enlisting our state in a program that may cease to exist on both constitutional and administrative grounds is, in my opinion, overly aggressive and fundamentally imprudent,'' Mr. Ball said.
Michael F. Cannon, the director of health policy studies at the Cato Institute, a libertarian research center in Washington, said that refusing to pass legislation to set up a health exchange was ''the most powerful blow that a state can strike against Obamacare,'' and questioned Mr. Cuomo's use of an executive order.
''King Andrew shouldn't be out creating new bureaucracies on his own,'' Mr. Cannon said. ''If the people's elected representatives say they don't want to create a new government bureaucracy, then the government doesn't have the power to create a new government bureaucracy.''
Since the passage of the Affordable Care Act, 11 states have set up insurance exchanges, according to the National Conference of State Legislatures. Ten did so with legislation; only one -- Rhode Island -- used an executive order, and a lawsuit challenging the authority of that order is pending.
Mr. Cuomo's office defended the use of an executive order, noting that the state would rely on federal financing to set up the exchange, rather than any new state spending, and that it would not set up a new governmental body. New York has already received $88 million in federal grants to plan for its health exchange; setting up the exchange will allow the state to seek additional federal financing.
''The activities that are necessary to implement the exchange are within the existing legal authority of the Department of Health, in which it will be based, and the other agencies with which it will work, including the Department of Financial Services,'' Mr. Cuomo's counsel, Mylan L. Denerstein, said in a statement.
Peter J. Kiernan, who served as chief counsel for former Gov. David A. Paterson, a Democrat, said that although ''legislation is always optimal,'' he believed the executive order was legal.
''In essence, he's telling the Department of Health, which works for him, to get ready to do this, and to use federal money that has already come through,'' Mr. Kiernan said. ''There may be people that would complain about it, but I don't think that anyone would be successful challenging the governor's authority here.''
A spokesman for the Senate Republicans declined to comment on the executive order. But after Mr. Cuomo said last month that he would set up the exchange using his own power, the Senate majority leader, Dean G. Skelos, a Long Island Republican, said the Senate Republicans would not be interested in challenging such a move.
''The governor has the right to issue executive orders,'' Mr. Skelos said. Still, he added, ''If somebody wants to sue him, fine.''
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November 5, 2013 Tuesday
Late Edition - Final
Strategic Move Exempts Health Law From Broader U.S. Statute
BYLINE: By ROBERT PEAR; Jackie Calmes contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1170 words
WASHINGTON -- The Affordable Care Act is the biggest new health care program in decades, but the Obama administration has ruled that neither the federal insurance exchange nor the federal subsidies paid to insurance companies on behalf of low-income people are ''federal health care programs.''
The surprise decision, disclosed last week, exempts subsidized health insurance from a law that bans rebates, kickbacks, bribes and certain other financial arrangements in federal health programs, stripping law enforcement of a powerful tool used to fight fraud in other health care programs, like Medicare.
The main purpose of the anti-kickback law, as described by federal courts in scores of Medicare cases, is to protect patients and taxpayers against the undue influence of money on medical decisions.
Kathleen Sebelius, the secretary of health and human services, disclosed her interpretation of the law in a letter to Representative Jim McDermott, Democrat of Washington, who had asked her views. She did not explain the legal rationale for her decision, which followed a spirited debate within the administration.
Under the Affordable Care Act, millions of people will be able to buy insurance from ''qualified health plans'' offered on exchanges, or marketplaces, run by the federal government and by some states.
Most of the buyers are expected to be eligible for subsidies to make insurance more affordable. The subsidies, paid directly to insurers from the United States Treasury, start in January and are expected to total more than $1 trillion over 10 years.
Ms. Sebelius said the Health and Human Services Department ''does not consider'' the subsidies to be federal health care programs. She reached the same conclusion with respect to federal and state exchanges, built with federal money, and with respect to ''federally funded consumer assistance programs,'' including the counselors, known as navigators, who help people shop for insurance and enroll in coverage through the exchanges.
The federal exchange has been plagued with problems since it opened on Oct. 1. The Obama administration said that the online enrollment system for the exchange was out of service again for 90 minutes on Monday afternoon in an ''unscheduled outage.'' That was in addition to the scheduled down time from 1 a.m. to 5 a.m. each day.
President Obama, speaking at a political event on Monday night, said he was determined to fix the problems that have frustrated millions of people trying to use the website for the federal exchange.
''When the unexpected happens, when the unanticipated happens, we're just going to work on it,'' Mr. Obama said. ''We're going to fix things that aren't working the way they should be. We're going to smooth this thing out, and we're just going to keep on going.' ''
Lawyers and law enforcement officials said Ms. Sebelius's decision was unexpected because the insurance exchanges and subsidy payments appeared to fit the definition of federal health care programs in the anti-kickback statute.
Generally, the law makes it a crime to pay or receive anything of value in return for the referral of patients or as an inducement for people to buy goods and services reimbursed by federal health care programs. Such programs are defined broadly as ''any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States government.''
''The secretary's decision will have some very significant consequences,'' said D. McCarty Thornton, former chief counsel to the inspector general at the Health and Human Services Department. ''The federal anti-kickback statute will, in most cases, not apply to subsidized health plans or the items and services furnished by those plans.''
''Plans and providers are very happy to be relieved of that concern,'' Mr. Thornton added.
Kevin G. McAnaney, a lawyer who specializes in health care fraud and abuse cases, said Ms. Sebelius's decision would allow drug companies to give coupons to people who buy insurance through the exchanges.
Such coupons subsidize co-payments and reduce out-of-pocket costs for consumers, encouraging them to use certain brand-name prescription drugs when lower-cost alternatives are available, Mr. McAnaney said.
The federal government has forbidden the use of drug coupons in Medicare and other federal health programs, saying they amount to a classic kickback scheme, with drug companies paying consumers to use their products.
Mark Merritt, the president of the Pharmaceutical Care Management Association, which represents benefit managers like Express Scripts and CVS Caremark, expressed a similar concern. ''The coupons steer consumers away from lower-cost alternatives to more expensive drugs, increasing costs to insurers and to the government,'' he said.
Coupons may drive down the co-payment for an expensive brand-name drug, but often, the insurer must pay much more than it would for a generic version of the medication.
Some drug companies and their lawyers had assumed that federal insurance subsidies were part of a federal health care program.
Drug coupons offered by Merck, for example, say that they are not valid for patients covered by Medicare, Medicaid or ''any qualified health plan purchased through a health insurance exchange established by a state government or the federal government.''
In a vivid demonstration of how the anti-kickback law can be applied, the Justice Department announced on Monday that Johnson & Johnson would pay more than $2.2 billion to resolve criminal and civil investigations. The government said the company had, among other things, paid kickbacks to doctors and nursing home pharmacies to promote the use of certain drugs. The company said the payments were ''lawful rebates.''
The National Health Council, which represents patients and drug companies, praised Ms. Sebelius's decision. ''People with chronic diseases and disabilities will be able to continue using co-payment assistance programs,'' said Myrl Weinberg, the chief executive of the council.
Ms. Sebelius may not have the last word, lawyers said. A whistle-blower could file suit under the False Claims Act, charging that health care providers, health plans or drug makers had defrauded the government, and a federal court might then decide whether the federal exchange or subsidy payments were federal health care programs.
Addressing a rally of supporters on Monday, Mr. Obama responded to critics who say he has broken his promise that people could keep their health insurance if they liked it.
Mr. Obama provided some additional explanation: ''Now if you have or had one of these plans before the Affordable Care Act came into law and you really liked that plan, what we said was you could keep it if it hasn't changed since the law was passed.''
In recent weeks, hundreds of thousands of people have received notices discontinuing individual insurance policies because they did not meet minimum coverage standards under the health care law.
URL: http://www.nytimes.com/2013/11/05/us/politics/federal-health-law-may-not-be-a-federal-health-care-program.html
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GRAPHIC: PHOTO: President Obama discussed the Affordable Care Act at a dinner in Washington. The administration has ruled that it is not subject to a specific anti-fraud law. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)
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March 30, 2012 Friday
Reporter Q. and A. on the Health Care Arguments
BYLINE: THE NEW YORK TIMES
SECTION: US; politics
LENGTH: 119 words
HIGHLIGHT: Reed Abelson and Adam Liptak of The Times answered readers' questions about the health care arguments in the Supreme Court.
On The Times's Facebook page on Thursday, Adam Liptak, the newspaper's Supreme Court correspondent, and Reed Abelson, a reporter covering health care for the Business Day section, hosted a discussion with readers about the legal battle over the Patient Protection and Affordable Care Act. Below is a transcript of highlights from the question-and-answer session.
[View the story "Facebook Q & A on Supreme Court Arguments" on Storify]
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June 26, 2015 Friday
Late Edition - Final
Court Ruling Seen as a Spur to Consolidation of Insurers
BYLINE: By MICHAEL J. de la MERCED
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1
LENGTH: 771 words
A new round of consolidation in the health insurance industry appeared closer as companies seek to grow larger, driven in part by cost-cutting and opportunities that are part of the Affordable Care Act.
In the latest jockeying, Humana, the smallest of the big five insurers, is pursuing a deal to sell itself and could reach an agreement by next week, according to a person briefed on the matter, who spoke on the condition of anonymity. Among those in the running to buy it are two bigger competitors, Aetna and Cigna.
The machinations of Humana -- set against a backdrop of frenzied merger discussions within the insurance industry -- received an extra jolt from the Supreme Court's ruling on Thursday that the government could furnish tax subsidies for poor and middle-class Americans to buy health insurance.
The long-awaited ruling, in the case King v. Burwell, was a major victory for the Obama administration that will greatly benefit large parts of the American health care system. Insurers, especially, had been counting on those billions of dollars in tax subsidies to draw in new customers, particularly as Medicare and Medicaid turn to private health plans to offer coverage. Many insurers, including Humana, issued statements in support of the court's decision.
Investors, too, were heartened by the ruling as shares in the major health insurers jumped on Thursday after the Supreme Court announced its decision. Trading in Humana's stock was briefly halted and its price gained more momentum after Bloomberg News reported that it was near a deal to sell itself.
Still, it remains to be seen whether government regulators will bless too many consolidations, because of antitrust concerns. And it is unclear what effect more mergers will have on the prices consumers pay for insurance.
Other parts of the American health care sector were also bolstered by the ruling, particularly hospitals, which are expected to benefit from an increase in paying customers who now are covered by Medicaid or subsidized private insurance. Shares in HCA Holdings, the huge hospital operator, rose nearly 9 percent, while those of Tenet Healthcare jumped 12 percent.
Affirmation for a signature feature of the Affordable Care Act will make firm for some time the ability of insurers to move into new markets. Yet insurers have also faced pressure to cut their costs, especially since these new customers are more sensitive to the price of health coverage.
That has propelled merger talks within the health insurance industry of an intensity unseen for the last several years, as companies vie to find the right partner and the kind of scale that will enable them to reduce costs and gain more negotiating power with health systems.
Insurers are also seeking deals with a sense of urgency, lest they risk being left out if government regulators limit the number of mergers that will be allowed to happen.
Already, Anthem has offered $47 billion to acquire Cigna, a deal that Cigna has rebuffed, potentially with an eye to buying Humana. Anthem itself had also expressed interest in buying Humana, though it is now focused on Cigna.
And UnitedHealthcare, the biggest of the health insurers, has made a preliminary approach for Aetna, people briefed on the matter said previously.
Humana, based in Louisville, Ky., is seen as attractive because of its big presence in the Medicare market, which has benefited from the Affordable Care Act. Aetna, Anthem and Cigna all have relatively smaller Medicare Advantage businesses.
But Humana has struggled to meet Wall Street's profit expectations for much of the last year, though it enjoyed rises in both its membership rolls and its revenue in the first three months of the year.
The company has been working with bankers at Goldman Sachs to sift through its potential deal options, fielding expressions of takeover interest from a number of suitors.
While Humana is perhaps the least expensive takeover target within the big five insurers, with a market value of $27.6 billion, it faces a few distinct issues.
Among them is that its rival with the biggest financial resources to pursue a transaction, UnitedHealthcare, would most likely be barred by government regulators because both companies have major operations tied to Medicare.
With UnitedHealthcare and Anthem both pursuing two of the most logical buyers of Humana, the smallest insurer risked being left alone -- and competing against far bigger rivals -- if it did not strike its own deal ahead of other potential transactions.
Representatives for Humana, Aetna and Cigna were not immediately available for comment.
URL: http://www.nytimes.com/2015/06/26/business/dealbook/humana-said-to-pursue-sale-as-courts-ruling-gives-insurers-a-lift.html
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The New York Times
March 30, 2016 Wednesday
Late Edition - Final
Policyholders Under Law Prove Sicker and Costlier
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 684 words
WASHINGTON -- People newly insured under the Affordable Care Act were sicker, used more medical care and had higher medical costs than those who already had coverage, the Blue Cross and Blue Shield Association said Tuesday in a new study of its policyholders.
Because insurers' premiums have to cover their medical expenses, the new report helps explain why Blue Cross plans have sought, and insurance commissioners have approved, substantial rate increases in many states. Another round of rate review is about to begin, with insurers generally required to file rate requests for 2017 in the next two months.
The findings are noteworthy because Blue Cross and Blue Shield plans operate across the country and have the largest share of the individual market in many states, giving them an unrivaled source of claims data.
In its report, the Blue Cross and Blue Shield Association examined the use of medical services by people who enrolled in its plans before and after major provisions of the Affordable Care Act took effect in 2014.
One of those provisions essentially required insurers to offer coverage to people who had previously been denied coverage because of their medical problems.
People newly enrolled in individual Blue Cross health plans in 2014 and 2015 were found to have higher rates of certain diseases and conditions, including high blood pressure, diabetes, depression, coronary artery disease, H.I.V. and hepatitis C, than people who already had coverage.
Diabetes was nearly twice as common among newly enrolled consumers as among those previously enrolled, the report said. Hepatitis C was more than twice as common, and H.I.V. was more than three times as common, it said.
Likewise, the report said, consumers newly enrolled in Blue Cross plans in 2014-15 used more medical services than those who first bought coverage before 2014. Hospital admission rates were 84 percent higher, it said, and the frequency of visits to doctors and other medical professionals was 26 percent higher.
Blue Cross said the study was based on claims for 4.7 million people. About one-third had been continuously enrolled since 2013; the others signed up in 2014 or 2015.
Administration officials said the study showed the need for the health care law, signed six years ago by President Obama. ''It's no surprise that people who newly gained access to coverage under the Affordable Care Act needed health care,'' said Ben Wakana, a spokesman for the Department of Health and Human Services. ''That's why they were locked out of coverage before.''
Alissa Fox, a senior vice president for the Blue Cross and Blue Shield Association, said the differences in the prevalence of disease could narrow as newly insured consumers receive care and medications to prevent and treat illnesses. Blue Cross companies have programs to help consumers ''get healthy faster and stay healthy longer,'' she said.
New insurance policies are often more generous and comprehensive than individual policies sold before the health care law. The new policies must, for example, cover maternity care and mental health and substance abuse services.
Some of the people buying insurance under the health care law come from states' ''high-risk pools,'' created specifically for people with cancer, heart disease or other serious medical problems.
In rate requests filed with state regulators in the last two years, many insurers said they had been aware of a pent-up demand for health care, but had underestimated how much care their new customers would require.
Researchers and health policy experts had predicted that people with higher medical costs would enter the market in the first few years of the public insurance exchanges. And the health care law provided special payments to insurers with unexpectedly high costs.
Federal and state officials and consumer advocates said they hoped that premiums would become more stable and predictable in the next couple of years.
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URL: http://www.nytimes.com/2016/03/30/us/politics/newest-policyholders-under-health-law-are-sicker-and-costlier-to-insurers.html
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(Economix)
September 27, 2013 Friday
A Health Care Fight That Punishes Federal Workers
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1753 words
HIGHLIGHT: The Affordable Care Act was not intended to deny a employer contribution to Congressional employees’ health coverage, and accusations that Congress is acting hypocritically in sponsoring such coverage are unfounded, an economist writes.
Updated | to clarify the contentions of critics about the law's application to Congressional staff members, and with a postscript correcting the legislative history of the Grassley amendment.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
One can think of the Affordable Care Act as a highly complex patch on the even more complex and fragmented health insurance system.
Thinking of it that way helps explain why even people who have no ideological dog in the hunt have such difficulty getting their mind around this complex legislation, especially from a worm's-eye view. It does not help that Americans are bombarded daily with misleading information about the act.
Viewing the law from a distance, one discerns two main objectives:
1. To facilitate easier and affordable access to health insurance to Americans who do not now have health insurance (and that latter phrase warrants emphasis).
2. To help reorganize the delivery of health care in the United States to enhance its cost-effectiveness by lowering the cost of producing a given level or quality of care or by enhancing the quality of care for a given cost, or both.
To the best of my knowledge, nowhere in its many pages does the law, either in its spirit or its wording, suggest that any employer - including the federal government - who currently sponsors health insurance for its employees and who makes contributions to the premiums for that coverage may no longer do so come Jan. 1.
And yet, some maintain that the law forces the federal government to drop such coverage for certain employees. Among them are the editors of , Michael Cannon of the libertarian Cato Institute and Robert Moffitt, Edmund Haislmaier and Joseph Morris of the Heritage Foundation.
These longstanding critics of the Affordable Care Act assert that its Section 1312(d)(3)(D) prevents the federal government from sponsoring health insurance for members of Congress and their staffs; they accuse the Office of Personnel Management of the Obama administration of breaking the law by exempting the targeted federal employers from this provision. Writing on the opinion page of The Wall Street Journal, for example, former Secretary of Education William Bennett and Christopher Beach speak of "The Hypocrisy of Congress's Gold-Plated Health Care."
Traditionally, members of Congress and all federal employees have been able to choose their private health insurance coverage from a wide array of policies offered by private health insurance on a federal health insurance exchange, the Federal Employee Health Benefits Program, operated by the Office of Personnel Management of the executive branch.
The premiums on this exchange have for decades been fully community-rated, as they are within companies under most employment-based health insurance systems, certainly among large employers. This means the premium quoted by a particular insurer was the same for every individual (and analogously for families), regardless of the health status or age of the insured.
The federal government has contributed to coverage of members of Congress and of all federal employees 72 percent of the average premium bid made by the various insurers on the exchange, or 75 percent of the premium of the health policy chosen by the employee, whichever is lower.
Most large private-sector employers make similar contributions, albeit a bit more generous, toward coverage for their employees. In that regard, the federal program is not really "gold-plated coverage" as Mr. Bennett and Mr. Beach suggest.
Effective Jan. 1, Section 1312(d)(3)(D) of the law forces members of Congress and their personal staff out of the exchange and onto the state-run or federally run, state-based health insurance exchanges established under the law, there to seek whatever coverage is offered on the relevant exchange.
These new exchanges, it must be emphasized, were not even intended for the great majority of employed Americans and their families who already have job-based, group health insurance with premiums that are community-rated within the company (although some smaller employers currently with small-group coverage and those with many low-wage workers may in the future take advantage of the federal subsidies offered on the new exchanges).
Rather, the new exchanges were designed mainly for the minority of Americans who have to buy coverage in the nongroup market, many millions of whom have pre-existing medical conditions and hitherto could not afford the high premiums they were quoted or were refused coverage outright.
For what it is worth, I view the requirement spelled out in Section 1312(d)(3)(D) as dubious, because it will create many avoidable headaches regarding the interface with Medicare and the Internal Revenue Service. To get a feel for these headaches, I refer readers to a lucid column written by Prof. Timothy Jost of the Washington and Lee School of Law on Aug. 7 and posted on the Health Affairs blog.
It may be helpful to present the relevant Subsection D of Section 1312(d)(3)(D), or the more intrepid can read the entire Section 1312 (starting on Page 64). Subsection D reads as follows:
(D) MEMBERS OF CONGRESS IN THE EXCHANGE.
(i) REQUIREMENT. Notwithstanding any other provision of law, after the effective date of this subtitle, the only health plans that the Federal Government may make available to members of Congress and congressional staff with respect to their service as a member of Congress or congressional staff shall be health plans that are:
(I) created under this act (or an amendment made by this act); or
(II) offered through an exchange established under this act (or an amendment made by this act).
(ii) DEFINITIONS. In this section:
(I) MEMBERS OF CONGRESS. The term "member of Congress" means any member of the House of Representatives or the Senate.
(II) CONGRESSIONAL STAFF. The term "congressional staff" means all full-time and part-time employees employed by the official office of a member of Congress, whether in Washington, D.C., or outside Washington, D.C.
That's it. Does it state in the section that the federal government may not continue to make the traditional employer-provided contributions to the targeted employees' health insurance?
As I read this short section, it says absolutely nothing about this issue, and I am by no means the first to assert this. Indeed, as early as April 2010, about a month after the act was signed into law on March 23, 2010, the legal staff of the nonpartisan Congressional Research Service, Congress's research arm, came to a similar conclusion in response to an inquiry on this point from Representative Tom Price, Republican of Georgia.
The legislative attorneys composing the carefully worded memo suggested to Mr. Price that the intent of the law was not to forbid the government from making contributions to the insurance coverage of the federal employees covered by the section. But they looked to the relevant federal agency to clarify the questions raised by Section 1312(d)(3)(D).
It may be asked how this dubious section ever found its way into the law. The idea of requiring Congressional employees to take part in the new exchanges was included in by an amendment proposed by Senator Charles Grassley, Republican of Iowa - but his amendment, unlike the final version, provided for the employer contributions to be maintained. (See the postscript below.)
Years ago, former Representative Pete Stark, Democrat of California, somewhat facetiously introduced a bill in the House of Representatives providing that all members of Congress should lose their employer-based insurance coverage until they had legislated a truly universal health insurance system in this country.
We now have the spectacle of Senators David Vitter, Republican of Louisiana, and Ted Cruz, Republican of Texas, eagerly seeking to abolish employer-based coverage for their colleagues and, if Senator Cruz has his way, for all personnel on the federal government's payroll, because Congress had tried at long last to extend insurance coverage to more Americans.
It would all be quite amusing, were it not so serious an issue.
Postscript
Comments submitted on my post have suggested that it was unfair to Senator Grassley, because in his own amendment to the bill eventually passed by the Senate he had anticipated the conundrum that has now emerged on Section 1312(d)(3)(D). It is a fair criticism. I accept it.
As the thorough legislative analysis for the Heritage Foundation by Messrs. Moffit, Haislmaier and Morris points out, the ultimate wording was not from Senator Grassley's amendment, which made explicit mention of the federal contribution toward health insurance of Congressional employees and members of Congress, as did a version approved by the Senate Finance Committee.
In subsequent legislative maneuvering (and despite Senator Grassley's efforts), this provision was unfortunately omitted, as it might have avoided the uncertainly on this point. (The final language was similar to an amendment by Senator Tom Coburn, an Oklahoma Republican, that was in the version reported out by a different Senate committee.)
In the absence of language like Senator Grassley's, Messrs. Moffit, Haislmaier and Morris state that under Chapter 89 of Title 5 of the U.S. Code, the government lacks the statutory authority to make employer contributions toward the health insurance of federal employees and members of Congress outside the Federal Employees Health Benefits Program.
In its own analysis of Section 1312(d)(3)(D), however, the Congressional Research Service suggested that "it seems that the section may provide the authority for the federal government to make a contribution to the health insurance premiums of Members of Congress." This analysis does not mention any conflict with Chapter 89 of Title 5 of the U.S. Code.
My own sense in this case is that it was not the spirit of the Affordable Care Act - nor Senator Grassley's intent - to pre-empt the federal contribution toward Congressional employees' health insurance. So to accuse Congress of a hypocritical carve-out over an issue that had best be viewed as sloppy legislation is not warranted, which was the main point of my post.
Health Coverage Worthy of a Senator
How to Gut Obamacare
Who Abandoned the Health Insurance Credit
The Path to Complexity on the Health Care Act
The Tax Equation in the Health Care Law
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February 5, 2015 Thursday
Late Edition - Final
G.O.P. Lawmakers Propose Alternative to Obamacare
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 926 words
WASHINGTON -- Three influential Republican members of Congress unveiled a comprehensive proposal on Wednesday to replace President Obama's health care overhaul with an alternative that would halt the expansion of Medicaid and scale back subsidies for middle-income people to buy private insurance.
The plan, drafted with encouragement from Republican leaders in the Senate and the House, would retain some consumer protections in the Affordable Care Act, but would reduce federal regulation of insurance policies. States would have more authority to specify the ''essential health benefits'' that must be provided by insurance. As an example, the federal government would no longer require insurance policies to include coverage for maternity care.
The proposal was devised by Senator Orrin G. Hatch of Utah, the chairman of the Finance Committee; Representative Fred Upton of Michigan, the chairman of the Energy and Commerce Committee; and Senator Richard M. Burr of North Carolina, a member of the Finance and Health committees.
In documents sketching their proposal, Republicans said their ''blueprint'' would lower costs and rebut criticism from Democrats who say the Republicans have no ideas on health care.
Republicans said the need for such an alternative had become more urgent because they now control both houses of Congress, and the Supreme Court could upend the president's health care law with a ruling later this year.
Their plan includes a potentially explosive proposal: Workers would have to pay federal income tax on the value of employer-provided health benefits that exceed certain annual thresholds -- $12,000 for individuals and $30,000 for families. Health benefits above those levels would be treated and taxed as regular income for the employee. The thresholds would increase over time.
Employers could still take tax deductions for the cost of employee health benefits as an incentive to continue providing coverage, Republicans said. Moreover, a summary of the proposal says that ''economists across the political spectrum largely agree'' that the current tax break for employer-provided insurance is fueling the growth of health costs.
Employees and employers have been vocal in their objections to proposals that would limit the tax break.
Sylvia Mathews Burwell, the secretary of health and human services, said Wednesday that almost 10 million people would have coverage this year through the public insurance marketplaces created under the Affordable Care Act. Nearly 7.5 million people have selected plans or were automatically re-enrolled through the federal exchange, she said, and 2.4 million people have been signed up through state-run exchanges.
Republicans said their plan did not include a federal exchange, but would allow states to run such marketplaces if they wanted to.
The Republicans did not provide a formal estimate of the cost of their proposal or the number of people who would be covered. Democrats have criticized such plans in the past, saying that they would not achieve the coverage gained under the Affordable Care Act.
The Republican plan would repeal the individual and employer mandates under which most Americans must carry insurance and larger employers must offer it to employees or else pay penalties.
''If consumers do not want to buy coverage, they don't have to,'' according to a document describing the Republican plan.
The Republicans would also repeal more than a dozen new taxes and fees, including taxes on insurance companies and manufacturers of prescription drugs and medical devices.
The government would offer subsidies, in the form of tax credits, for the purchase of ''health care coverage or services,'' according to the proposal. The subsidies would be available to people with incomes up to three times the poverty level (up to $35,300 for an individual), compared with four times the poverty level under the Affordable Care Act.
Lower-income and older people would receive larger subsidies, but the average amount would be less than the current subsidies, which, according to the Congressional Budget Office, are now expected to total $1 trillion over 10 years.
Under the Republican proposal, the government would provide a ''capped allotment'' to states to finance coverage for certain Medicaid beneficiaries. Money would be allocated according to the number of poor people in each state. The amount would increase at the rate of the Consumer Price Index plus one percentage point and would ''reflect demographic and population changes.''
Republicans said Medicaid expansion under the current law was financially unsustainable.
The Republican proposal says that ''no one can be denied coverage based on a pre-existing condition,'' but this guarantee would apply mainly to people who had been continuously covered by insurance. For people who are uninsured, the Republican plan envisions ''a one-time open enrollment period in which individuals would be able to purchase coverage regardless of their health status or pre-existing conditions.''
Republicans would still allow young adults to stay on their parents' health care plan until age 26, but states could ''choose to opt out of this provision.''
The government would allow more variation in premiums based on the age of policyholders. Under current law, insurers generally cannot charge older Americans more than three times what they charge younger people, other factors being equal. Republicans would allow a ratio of five to one, with states permitted to set more or less restrictive rules.
URL: http://www.nytimes.com/2015/02/05/us/politics/gop-lawmakers-propose-alternative-to-obamacare.html
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November 6, 2014 Thursday
Late Edition - Final
G.O.P Win Is Expected to Open Some Doors
BYLINE: By NELSON D. SCHWARTZ and CLIFFORD KRAUSS
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1
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After years of gridlock in Washington, American business is gearing up for a major push on long-sought goals like an overhaul of the corporate tax system, building the Keystone XL oil pipeline, lighter environmental and financial regulation and winning congressional backing for trade deals with Asia and Europe. Business interests face a much more receptive audience now that Republicans are poised to control both the House and Senate next year.
But despite plenty of public talk of more aggressive action -- like a rollback of the Affordable Care Act or the Dodd-Frank rules passed after the financial crisis -- lobbyists, experts on Wall Street and political veterans say the actual legislative agenda will be much more limited.
''There is a pent-up demand for legislative action, and there was a logjam because of the campaign,'' said Bill Miller, a veteran lobbyist and senior vice president at the Business Roundtable, which represents a wide cross-section of the biggest American companies.
''The three issues we've got teed up now are corporate tax reform, then immigration reform, as well as getting new trade agreements passed.''
While many of the more conservative Republicans elected on Tuesday made their opposition to the Affordable Care Act a touchstone of their campaigns, there is much less appetite on the part of business leaders for wholesale changes to the health care law.
For one thing, many of the insurance exchanges are finally working well, and businesses have adapted to the new landscape. Even more important, added demand from the newly insured is likely to increase profits in sectors like hospitals, pharmaceuticals and medical devices.
''Anything regarding the Affordable Care Act is going to be a stretch,'' said John K. Lynch, regional chief investment officer for Wells Fargo Private Bank.
Similarly, insiders in Washington and on Wall Street say any effort to reverse the Dodd-Frank financial overhaul or completely defang the Consumer Financial Protection Bureau is unlikely to succeed.
Not that some opponents won't try. Senator Richard C. Shelby, an Alabama Republican who is slated to be the next chairman of the Senate Banking Committee, has called the bureau ''the most powerful yet unaccountable bureaucracy in the federal government.''
One possible compromise might be the creation of a five-member panel of commissioners to oversee the bureau, experts said, much like the ones that oversee the Securities and Exchange Commission and several other regulatory agencies.
''There will be a lot of hyperbole and table-pounding, but the outcome will be incremental, not overwhelming,'' said Steve Bartlett, a former Republican lawmaker from Texas who served as chief executive of the Financial Services Roundtable, an industry group, from 1999 to 2012. ''The C.F.P.B. isn't going away, and I've told companies that.''
Business leaders sounded an optimistic note in the wake of the election Wednesday, while also acknowledging that Washington may not change its ways.
''There's been dysfunction for the last several years in the leadership of both political parties and both branches of government,'' said Doug Oberhelman, chief executive of Caterpillar.
''People are fed up, and this should be a wonderful wake-up call for our leaders,'' he said. ''Both parties should hear it, and if they don't we're headed for a really big tidal wave in 2016.''
After pouring hundreds of millions of dollars into the most expensive midterm election in history, corporate donors are eager to see their agenda tackled by a party that has traditionally been much more sympathetic to big business.
''With the Republicans controlling both houses, the corporations that have been financing their campaigns for years are going to expect to see a return on their investment,'' said Robert J. Shapiro, who was a top Commerce Department official in the Clinton administration and is now chairman of Sonecon, a Washington economic and security consulting firm.
He foresees a big push to lower the corporate tax rate while closing some loopholes so that the package does not reduce overall revenue for the government.
American companies have also been pressing Washington for a deal that would let them bring back profits earned overseas without incurring the current 35 percent federal tax rate on corporate earnings.
Known as repatriation, advocates say it could bring back the roughly $2 trillion in earnings companies have stashed abroad for new investments or dividends in the United States. As with the rest of corporate tax reform, broad changes in tax law like this have proved elusive in the past, but President Obama has suggested a possible deal in which some of the revenue from that move would be used to help finance investments in infrastructure projects.
''There's a great desire for it, and the idea of tax reform is great, but the details are really tough,'' said Tony Fratto, who served in the White House and the Treasury Department under President George W. Bush, and is now a top communications consultant for companies like G.E. and several major financial services firms at Hamilton Place Strategies in Washington.
In addition, any tax break for business would be a tough sell at a time when many Americans remain frustrated with the economy and have not profited much from a booming stock market or surging corporate profits.
''The beneficiaries will be multinationals with business overseas,'' Mr. Fratto said. ''I believe it would help the economy but it's hard to explain politically.''
In theory, new trade deals with Europe and Asia have support from the White House and many Republicans, but rounding up the votes to pass them will also prove politically difficult.
An overhaul of immigration laws is an even tougher issue because there are deep divisions within the Republican Party on how to change the system, Mr. Shapiro said, with the conservative base at odds with the desire of business to make it easier for immigrants to establish legal status in the United States.
By contrast, there is more of a common denominator among Republicans on easing government supervision of business. ''Both the Tea Party types and the establishment wing of the Republican Party agree on wanting less regulation,'' Mr. Shapiro said.
The Republican takeover of the Senate is likely to sharpen debate on a number of energy issues, and, with support from several Democrats from energy-rich states, put pressure on President Obama to finally decide whether to allow the Keystone XL pipeline to be built to connect Canadian oil sand fields with American refineries on the coast of the Gulf of Mexico.
Republicans in Congress are also expected to try to curb plans by the administration to control greenhouse gas emissions by imposing strict new rules on coal-fired power plants.
Oil executives expressed exuberant satisfaction with the election results.
''The Republican-controlled Congress can start making the president make some decisions on energy matters -- from the Keystone XL pipeline to lifting the ban on crude exports,'' said James W. Noe, a senior vice president of Hercules Offshore, a drilling company that works in the shallow waters of the Gulf of Mexico.
The Republican Senate victory is also expected to elevate Senator Lisa Murkowski of Alaska to chairwoman of the Energy Committee. She has been a strong advocate for enabling liquefied natural gas exports, and she can also be expected to oppose any new rules aimed at limiting hydraulic fracturing in shale oil and gas fields.
URL: http://www.nytimes.com/2014/11/06/business/republican-election-victory-seen-as-positive-for-business-but-others-temper-expectations.html
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REGULATION: Richard Shelby, right, expected to head the Senate Banking Committee, is a critic of financial regulation.
TRADE: Proposed agreements will get a fresh look, among them a 12- nation Pacific partnership that includes Japan. (PHOTOGRAPHS BY TOM PENNINGTON/GETTY IMAGES
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December 10, 2014 Wednesday
Late Edition - Final
Economist Says He's Sorry for 'Arrogance' on Health Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 22
LENGTH: 793 words
WASHINGTON -- Jonathan Gruber, the health economist whose incendiary comments about ''the stupidity of the American voter'' have embarrassed the Obama administration, apologized on Tuesday for what he described as his ''glib, thoughtless and sometimes downright insulting comments.''
''I am not a political adviser nor a politician,'' said Dr. Gruber, a professor at the Massachusetts Institute of Technology who was a paid consultant to the Obama administration in 2009 to 2010.
Dr. Gruber minimized his role, saying he had used an ''economic microsimulation model'' to help the administration and Democrats in Congress assess the impact of policies in the Affordable Care Act. He later defended the law in a number of speeches. In one, he said the law had been adopted, in part, because of the stupidity of voters and a ''lack of transparency'' about its financing.
Testifying on Tuesday before the House Committee on Oversight and Government Reform, Dr. Gruber said: ''I behaved badly, and I will have to live with that, but my own inexcusable arrogance is not a flaw in the Affordable Care Act. The A.C.A. is a milestone accomplishment for our nation that already has provided millions of Americans with health insurance.''
The chairman of the committee, Representative Darrell Issa, Republican of California, said backers of the law had passed it and sold it to the public with half-truths and deception. He added that Dr. Gruber and the administration had displayed ''a pattern of intentionally misleading the public about the true nature and impact of Obamacare.''
The senior Democrat on the committee, Representative Elijah E. Cummings of Maryland, joined in the criticism of Dr. Gruber. He said his comments were ''absolutely stupid'' and ''incredibly disrespectful.'' Worse, he said, the statements gave Republicans ''a political gift in their relentless campaign to tear down'' the law.
Mr. Issa showed a video in which Dr. Gruber suggests that supporters of the health law had written it in such a way that the Congressional Budget Office would not count required premium payments as tax revenue.
''This bill was written in a tortured way to make sure C.B.O. did not score the mandate as taxes,'' Dr. Gruber says in the October 2013 video. ''Lack of transparency is a huge political advantage. And basically, call it the 'stupidity of the American voter' or whatever, but basically that was really, really critical to getting the thing to pass.''
He appeared to squirm on Tuesday under questioning by Republicans who confronted him with his own past statements. He did not deny or recant those statements, but said he regretted some of his impolitic formulations. ''I made a series of statements that were really just inexcusable,'' Dr. Gruber said toward the end of the four-hour hearing.
''It is never appropriate to try to make oneself seem more important or smarter by demeaning others,'' he also said. ''I know better. I knew better. I am embarrassed, and I am sorry.''
Dr. Gruber infuriated Republicans on the committee by refusing to disclose the total amount of money he had received in grants and contracts from the federal government and states for work related to the Affordable Care Act. He also declined to say if he would provide copies of documents that he had prepared for federal and state agencies.
Representative Jason Chaffetz, Republican of Utah, told Dr. Gruber: ''You have been paid by the American taxpayers. Will you provide that information to this committee?''
Dr. Gruber replied repeatedly, ''You can take it up with my counsel.''
In an interview, Mr. Chaffetz said he would insist on the requests after he becomes the panel's chairman in January. ''Mr. Gruber will cough up those documents one way or another,'' he said.
Though he strongly supports the health law, Dr. Gruber has made statements that appear to undercut arguments now being pushed by the Obama administration in court cases challenging the payment of premium subsidies in states using the federal insurance exchange. Under the law, the federal government provides a backstop if states fail to establish exchanges.
''What's important to remember politically about this is if you're a state and you don't set up an exchange, that means your citizens don't get their tax credits,'' Dr. Gruber said in 2012.
By contrast, the White House has said that Congress intended for the subsidies to be available nationwide, in all states, regardless of whether they had a federal or state-run exchange.
Dr. Gruber said his earlier comments had been referring to the possibility that the federal government might not create a federal exchange.
''Your new explanation of your previous public statements makes little sense,'' Representative Justin Amash, Republican of Michigan, told him.
URL: http://www.nytimes.com/2014/12/10/us/jonathan-gruber-of-mit-regrets-arrogance-on-health-law.html
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(Ross Douthat)
November 7, 2013 Thursday
Different Kinds of Health Care Disruption
BYLINE: ROSS DOUTHAT
SECTION: OPINION
LENGTH: 1266 words
HIGHLIGHT: Comparing Obamacare’s disruption of existing insurance policies to the possible impact of conservative alternative.
After yesterday's detourinto electoral politics, let's turn back to the health care debate. Last week, amid the ongoing coverage of rising premiums and cancelled plans, the health care law's defenders took a new tack, arguing that the most plausible conservative alternatives to Obamacare would involve even more disruption of existing arrangements - with the implication being, then, that Republican outrage over "rate shock "is either straightforwardly cynical or else a sign that the G.O.P. would never, ever be willing to embrace a reform that disrupts the status quo at all.
This argument has some merit, for the reasons Philip Klein elaborated on here: You can't have health care reform without some kind of insurance disruption, and a Republican would-be reformer who made an Obama-esque "keep your plan" promise would either be exposed as a liar with similar alacrity or end up never actually undertaking reform at all. (This is yet another reason why a total death-spiraling exchange failure, coupled with a relative successful Medicaid rollout, would not necessarily leave conservative reformers in an ideal political spot.)
But I also think it's useful to think about the differences between the kind of disruption that would accompany the most plausible conservative alternative to Obamacare and what we're actually witnessing today, because it helps clarify whether the Affordable Care Act actually represents what Jonathan Chait, speaking for the defense, calls "the least-disruptive, least-painful way" to expand insurance coverage.
The conservative alternative I have in mind is not what you might call "the full McCain" - the conversion of the existing employer tax exclusion for health insurance into a universal credit, which is an elegant idea in conception but which would indeed disrupt existing arrangements more dramatically than the Affordable Care Act, and which (on the evidence of the 2008 campaign) is about as politically sale-able as single payer. Rather, it's the more modest plan the American Enterprise Institute's James Capretta has done the most work fleshing out, in which a cap on the employer deduction helps pay for a flat credit available only to those Americans who don't receive coverage through their workplace.
Liberals object to this plan for a variety of reasons: The credit would fund catastrophic coverage rather than the comprehensive insurance they prefer, and it would require expanding high-risk pools to cover current uninsurables rather than folding them into the existing insurance system. But on the specific question of existing-plan disruption - who bears the burden of reform, and why - I think the Capretta plan has advantages over Obamacare that even liberals should be able to recognize.
That's because the way our system is set up right now, anyone who buys insurance on the individual market has been persistently disadvantaged, and often dramatically so, relative to anyone who gets insurance through their employer, because employer-provided insurance comes with an effective government subsidy ("worth more than $5,000 on a $13,000 employer-sponsored plan" for an upper middle class family, Capretta points out) while the individual marketplace does not. So a cap on the employer tax exclusion, while disruptive, would make the system fairer in clear, uncomplicated ways: It would curb a tax subsidy that mostly benefits people with higher incomes and only benefits people with expensive insurance plans, and extend that subsidy to people who have had to pay more, often much more, for insurance up until now.
By contrast, the Obamacare approach loads much more of the financial burden of reform on to the individual market, creating a stark, even chasm-like divide between that market's winners and losers and leaving the latter doubly-shafted: They still don't get a tax subsidy and their plans are getting a lot more expensive into the bargain.
Some of these losers are well-off, yes. But many of them are middle class, and not necessarily better off than the people who would lose out under an employer-exclusion cap. Moreover, there's a significant difference between what such a cap would actually do to people with employer-provided insurance and what Obamacare does to people with less-expensive individual market plans. The cap would basically give employers and employees a choice: Keep the expensive plans you currently have with higher premiums and co-pays attached (or with a higher tax bill at the end of the year), or shift down to plans with higher deductibles, network limitations, and so forth. This is not an easy choice by any means, and it would undoubtedly lead to the equivalent of some of the unhappy stories associated with Obamacare's regulations - people who feel like they can no longer afford coverage they like, people who end up losing access to their doctors and hospitals because their employer stops offering a plan, and so on. But I would submit that it's actually more humane to expose the already-subsidized to more of the real costs associated with their expensive insurance than it is to tell the persistently-unsubsidized that their most affordable insurance options are being outlawed, and that they are now required by law to pay more for more coverage (or, as often seems to be the case, to pay more for less).
What's more, as Reihan Salam points out in an exchange with Salon's Brian Beutler, this isn't an either-or choice, because Obamacare too includes a kludge-y version of the employer tax deduction cap in the form of the excise (or "Cadillac") tax on high-cost insurance plans: It's just set a higher threshold and thus applies to fewer policies than would the conservative alternative. That tax isn't scheduled to be implemented till 2018 (or year two of the Christie administration, if you prefer), so its effects aren't being fully felt as yet - but as the date gets closer, that provision will lead to rate increases and policy changes at the more expensive end of the employer market as well. So in comparing the potential disruptive effect of Capretta's cap-and-credit approach to the Affordable Care Act, you have to look at the complete picture: What we're seeing from Obamacare right now is only the beginning of the disruptions to existing plans, and today's individual market losers are only the first wave of people to whom the president's "keep your plan" promise doesn't actually apply.
The choice, then, isn't between gouging a few million people in the individual market or gouging a much larger number in the employer-based market. It's between a reform (the conservative alternative) that concentrates its disruptive impact the heretofore-oversubsidized portion of the marketplace, while trying to make the individual market more affordable for everyone who buys there, or a reform (Obamacare) that's disruptive for some people in the employer market but continues to protect most of them from the true price of their insurance, while pushing more of the off-budget cost of reform on to individual market premiums.
There are enough moving parts and unknown unknowns in each alternative that it's hard to say for sure which would one would ultimately be more disruptive in absolute terms (or even to define what those "absolute terms" would be). But I think there are various metrics - simplicity, equity, the choices left available and the incentives created - on which the conservative option might come out ahead.
What Is Reform Conservatism?
The Republican Health Policy Trainwreck
Was Rate Shock Necessary?
Obamacare's Losers and Why They Matter
Why Not Medicaid For All?
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May 2, 2016 Monday 00:00 EST
States Can Contain Health Care Costs. Here's How.;
Op-Ed Contributors
BYLINE: RICHARD M. SCHEFFLER and SHERRY GLIED
SECTION: OPINION
LENGTH: 994 words
HIGHLIGHT: Health care providers are consolidating. So are insurers. Regulation combined with competition can ensure consumers see the savings.
THE architects of the Affordable Care Act counted on competition in the health insurance market to keep costs down and quality high. While the law has accomplished many of its coverage and cost-containment goals, its vision of a more competitive insurance market seems to be fading.
The nation's second-largest health insurer, Anthem, is poised to acquire Cigna, the fourth-largest. Aetna, the third-largest insurer, is seeking to acquire Humana, the fifth-largest. If approved by the Justice Department, these mergers would produce companies controlling about 35 percent of the health insurance market. These mergers would likely leave that market with far fewer competitors - a disappointing result for those who hoped it would increase "choice and competition." Yet our research suggests that this apparent failure obscures a potential path to success, one that lies between competition and a fully regulated market.
One reason behind the mergers is continued consolidation among hospitals and physician groups. From 2000 to 2013, the number of hospitals that were part of multisite health systems increased by 25 percent. More doctors are working for hospitals or for practices partly owned by hospitals; today, fewer than 20 percent of doctors are in solo practice. As provider organizations become larger, they gain more leverage in reimbursement-rate negotiations with insurers. To re-establish the bargaining balance between providers and insurers, insurers argue that they too must also get larger.
Our recently published research comparing New York and California, as well as previous analyses, suggest that there's truth to the insurers' argument. Consolidation in provider markets does raise health care prices. Insurer consolidation does reduce the prices paid to hospitals and physicians. Without further intervention, however, those price reductions don't get passed along to consumers.
The health care law offers an answer. Under the act, states have some flexibility in designing their marketplaces. States could, for instance, either accept all insurers who seek to participate or select a limited number to sell coverage. New York chose the first course, permitting all willing insurers to join; California chose the second, selecting 12 of the 32 insurers that initially showed interest.
This choice was critical because Covered California, the state's marketplace, used its leverage in selecting plans to keep initial premiums low. Before the marketplace opened, Covered California calculated how high premiums would need to be to cover the risks of covered populations and still generate a 2 percent profit for the insurers. California used these targets to select which insurers would be permitted to enter the market in the initial round. Then the state made a promise: Among those bidding for the first round, only those health plans selected would be permitted to offer plans for three years, except under unusual circumstances.
California also went further than New York in standardizing coverage. Under the Affordable Care Act, insurers in all marketplaces must offer a defined set of "essential health benefits" in all plans, and may offer plans at four coverage levels: platinum, the most comprehensive and expensive plans, followed in descending order of cost and coverage benefits by gold, silver and bronze. California went beyond this standardization by requiring that within each coverage level, all insurers offer the same deductibles and cost-sharing, and cover identical benefits. This made it easier for consumers to shop on price alone, rather than allowing insurers to obscure higher prices through complex and opaque benefit designs.
New York, by contrast, permitted insurers to offer not just standard plans, but also alternative plans with different cost-sharing and benefit designs.
When we examined the two states, we found that the effect of insurer competition differed greatly. In both states, areas with more hospitals had lower premiums compared with areas with fewer hospitals. But in New York, areas with fewer insurers had higher premiums, suggesting that insurers kept the benefits of greater bargaining power for themselves.
In California, by contrast, areas with fewer insurers also had lower premiums. Why? With initial premiums set at modest but adequate levels, and a vibrant marketplace, there was no need to further threaten insurers who might consider large premium increases. If an insurer tried to raise its premiums too far, consumers could easily shop among the restricted set of insurers for an identical product and switch to an alternative plan. Even in areas with fewer insurers, competition was sufficient to keep cost growth down.
The lesson here is that, especially in a health care system that is becoming more concentrated, competition and regulation can work together. A third party - governmental or quasi-governmental - can use its purchasing power to ensure that negotiating better health care prices benefits consumers, not just insurers.
Other states are getting into the act. Rhode Island has given its Department of Insurance authority to limit the price increases of inpatient and outpatient services; Massachusetts and Colorado have commissions that monitor costs and recommend action to the legislature to keep increases in health care under control.
Over time, we will learn more about how these alternative designs work. But one point is already clear: The choice between regulation and competition is a false one. To best manage our health care system, we will need both.
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Richard M. Scheffler is a distinguished professor of health economics and public policy at the University of California, Berkeley. Sherry Glied is the dean and a professor of public service at the Robert F. Wagner Graduate School of Public Service at New York University.
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February 17, 2014 Monday
Late Edition - Final
Writers Guild Plans Forum on Affordable Care Act
BYLINE: By MICHAEL CIEPLY
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 6
LENGTH: 366 words
LOS ANGELES -- On Tuesday night, an expected crowd of 100 or so screenwriters and others will gather in Lower Manhattan at the headquarters of the Writers Guild of America East to hear thoughts about the Affordable Care Act and its place in comedy and drama.
But whether any movie and television scripts that happen to be affected will have audiences laughing or crying about Obamacare still is not clear.
''This is such a contentious issue, no one's pretending'' there will not be robust disagreements on-screen, as in life, said Martin Kaplan, who spoke by telephone last week about the seminar, which drew criticism as a potential propaganda-fest in favor of the law when word of it surfaced last month.
Mr. Kaplan, as director of the University of Southern California's Norman Lear Center, helped organize the gathering under a grant made last fall by the California Endowment. That health-oriented nonprofit organization was financed by the insurance industry in a transaction that years ago turned WellPoint Health Networks into a publicly traded entity separate from the Blue Cross nonprofit group that had created it.
Early reports said the Lear Center and the endowment would work to promote enrollment in insurance plans under the new health law.
But after months of rancorous debate over the law and its troubled introduction, Mr. Kaplan and Michael Winship, president of the Writers Guild of America East, who spoke in a joint interview, were taking a more subdued approach.
''This is not about advising writers; we're in search of information,'' Mr. Winship said. He and Mr. Kaplan emphasized that conflicting views on Obamacare should be welcome in entertainment, as long as they are based in fact.
''Those writers can have any point of view they want,'' Mr. Kaplan said.
''If they think things went downhill when the 'public option' came off the table, that's O.K. too.''
Still, Tuesday's panel is not exactly packed with opponents of the law. It will be moderated by Mr. Kaplan and Mr. Winship, and includes Wendell Potter, a former insurance executive who has publicly defended Obamacare, and Julie Green Bataille, from the federal government's Centers for Medicare and Medicaid Services.
URL: http://www.nytimes.com/2014/02/17/business/media/writers-guild-plans-forum-on-affordable-care-act.html
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March 19, 2012 Monday
Late Edition - Final
Hurray For Health Reform
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 21
LENGTH: 798 words
It's said that you can judge a man by the quality of his enemies. If the same principle applies to legislation, the Affordable Care Act -- which was signed into law two years ago, but for the most part has yet to take effect -- sits in a place of high honor.
Now, the act -- known to its foes as Obamacare, and to the cognoscenti as ObamaRomneycare -- isn't easy to love, since it's very much a compromise, dictated by the perceived political need to change existing coverage and challenge entrenched interests as little as possible. But the perfect is the enemy of the good; for all its imperfections, this reform would do an enormous amount of good. And one indicator of just how good it is comes from the apparent inability of its opponents to make an honest case against it.
To understand the lies, you first have to understand the truth. How would ObamaRomneycare change American health care?
For most people the answer is, not at all. In particular, those receiving good health benefits from employers would keep them. The act is aimed, instead, at Americans who fall through the cracks, either going without coverage or relying on the miserably malfunctioning individual, ''non-group'' insurance market.
The fact is that individual health insurance, as currently constituted, just doesn't work. If insurers are left free to deny coverage at will -- as they are in, say, California -- they offer cheap policies to the young and healthy (and try to yank coverage if you get sick) but refuse to cover anyone likely to need expensive care. Yet simply requiring that insurers cover people with pre-existing conditions, as in New York, doesn't work either: premiums are sky-high because only the sick buy insurance.
The solution -- originally proposed, believe it or not, by analysts at the ultra-right-wing Heritage Foundation -- is a three-legged stool of regulation and subsidies. As in New York, insurers are required to cover everyone; in return, everyone is required to buy insurance, so that healthy as well as sick people are in the risk pool. Finally, subsidies make those mandated insurance purchases affordable for lower-income families.
Can such a system work? It's already working! Massachusetts enacted a very similar reform six years ago -- yes, while Mitt Romney was governor. Jonathan Gruber of the Massachusetts Institute of Technology, who played a key role in developing both the local and the national reforms (and has published an illustrated guide to reform) has surveyed the results -- and finds that Romneycare is working pretty much as advertised. The number of people without insurance has dropped sharply, the quality of care hasn't suffered, and the program's cost has been very close to initial projections.
Oh, and the budgetary cost per newly insured resident of Massachusetts was actually lower than the projected cost per American insured by the Affordable Care Act.
Given this evidence, what's a virulent opponent of reform to do? The answer is, make stuff up.
We all know how the act's proposal that Medicare evaluate medical procedures for effectiveness became, in the fevered imagination of the right, an evil plan to create death panels. And rest assured, this lie will be back in force once the general election campaign is in full swing.
For now, however, most of the disinformation involves claims about costs. Each new report from the Congressional Budget Office is touted as proof that the true cost of Obamacare is exploding, even when -- as was the case with the latest report -- the document says on its very first page that projected costs have actually fallen slightly. Nor are we talking about random pundits making these false claims. We are, instead, talking about people like the chairman of the House Republican Policy Committee, who issued a completely fraudulent press release after the latest budget office report.
Because the truth does not, sad to say, always prevail, there is a real chance that these lies will succeed in killing health reform before it really gets started. And that would be an immense tragedy for America, because this health reform is coming just in time.
As I said, the reform is mainly aimed at Americans who fall through the cracks in our current system -- an important goal in its own right. But what makes reform truly urgent is the fact that the cracks are rapidly getting wider, because fewer and fewer jobs come with health benefits; employment-based coverage actually declined even during the ''Bush boom'' of 2003 to 2007, and has plunged since.
What this means is that the Affordable Care Act is the only thing protecting us from an imminent surge in the number of Americans who can't afford essential care. So this reform had better survive -- because if it doesn't, many Americans who need health care won't.
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April 16, 2014 Wednesday
Stealth Taxes Are Still Income Taxes
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 785 words
HIGHLIGHT: The Affordable Care Act imposes economic burdens that are the equivalent of taxes, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
For most Americans, the individual income tax returns they have filed over the last days and weeks are not much different than they were 10 years ago. But, in fact, taxes have changed dramatically over that period, behind the scenes and in support of health reform.
Western European governments have long provided medical assistance to all of their citizens, regardless of age or income. In contrast, the United States government has covered its poor, elderly and disabled and left the remaining majority of the population to privately finance its health care.
It's not an accident that, by offering less coverage, America had lower health insurance payroll tax rates. The table below shows the rates for nine or ten other countries. (A number of countries are omitted because they do not have a specific payroll tax earmarked for their public health programs, although they do have public health programs and need a lot of taxes to pay for them. The countries also have different ways of collecting their payroll taxes, so my table translates their rates into an effective rate on employee paychecks that is economically comparable across countries).
Germany's government, for example, has a medical benefits payroll tax that is more than triple that in the United States. The average health insurance payroll tax rate in Western Europe has been more than twice as high as the rate in the United States. The contrast between the United States before the passage of the Affordable Care Act and Western Europe is consistent with the common sense idea that universal health coverage has a cost in the form of taxation of labor market activity. This is not to say that one system is better than the other. The point is that benefits appear to come with costs: more coverage requires higher tax rates.
If the United States government were to follow those in Western Europe and cover all of its citizens, one might guess that its payroll tax rates would have to be roughly four or five percentage points higher than they would be without universal coverage.
Yet the conventional wisdom is that the United States is now expanding coverage with hardly any new taxes on middle-class workers. In response to a request from Senator Tom Coburn, Republican of Oklahoma, the Joint Committee on Taxation named a few of the health care law's tax provisions as "directly affecting" individuals earning less than $200,000 annually and families earning less than $250,000, but they are relatively minor: On the order of $10 billion per year in an economy larger than $17 trillion.
As an official of the Department of Health and Human Services (it runs federal health programs) told The Washington Examiner, "The health care law will improve the affordability and accessibility of health care without significantly affecting the labor market."
Is it possible that, in writing the health care reform bill, America discovered a radical new way of financing public health coverage expansions without significantly burdening its labor market with taxes? Have the decades of high Western European payroll tax rates been unnecessary for governments to provide medical coverage for their nonelderly citizens? The answers are no.
The health overhaul contains a variety of hidden taxes - provisions that politicians and journalists do not call taxes, but nonetheless are the economic equivalent of taxes - that in combination have a lot in common with the payroll taxes that Europeans use to pay for their public medical programs.
For the most part, the new hidden taxes are economically equivalent to either employment taxes or income taxes. The hidden employment taxes require people with jobs to pay more to, or receive less from, the Treasury because they have a job. The foremost economic consequence of hidden employment taxes is less employment.
The law's hidden income taxes require people with high incomes to pay more to, or receive less from, the Treasury than people with low incomes do. Regardless of whether more taxes are collected from high-income families, more "means-tested" subsidies are paid to low-income families, or both, and the essential consequence is the same: less income.
In a forthcoming book and in commentaries, I will bring the new hidden taxes out into the open, quantify them and forecast their likely consequences for the labor market and the wider economy.
The Affordable Care Act's Multiple Taxes
Policies That Discourage Full-Time Work
Medicaid and the Incentive to Work
How to Gut Obamacare
Obamacare vs. Romneycare: The Labor Impact
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April 27, 2017 Thursday
Late Edition - Final
New Health Bill Has the Support Of Conservatives
BYLINE: By JENNIFER STEINHAUER and ROBERT PEAR; Thomas Kaplan contributed reporting.
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WASHINGTON -- The House Freedom Caucus, a group of hard-line conservatives who were instrumental in blocking President Trump's plan to repeal the Affordable Care Act last month, gave its approval Wednesday to a new, more conservative version, breathing new life into Republican efforts to replace President Barack Obama's health law.
Senior White House officials, led by Reince Priebus, the chief of staff, have relentlessly pressed Republicans to revive the health care push before Mr. Trump's hundred-day mark on Saturday, and with conservatives falling into line, the bill has a chance to get through the House, possibly as early as Friday.
It was not clear whether conservative support for the revised legislation would be matched by losses in the center, especially among Republicans representing districts won by Hillary Clinton. But the rest of the House Republican Conference was left with a stark choice: Reject the measure and take the blame previously left at the feet of conservatives for undermining a central goal of the administration, or give it the nod, please voters who want a repeal, and risk taking a potentially fatal hit in the next election for approving a measure expected to leave tens of millions of Americans without insurance.
''Members went home and got an earful,'' said Representative Tom Cole, Republican of Oklahoma, saying that voters were wondering, ''Why can't you get something done?'' Mr. Cole said he was now ''cautiously optimistic'' that the measure could pass on the floor.
The latest proposal, drafted by Representative Tom MacArthur, a moderate Republican of New Jersey, would allow states to obtain waivers from federal mandates that insurers cover certain ''essential health benefits,'' like emergency services, maternity care, and mental health and substance abuse services, which many Republicans argue have driven up premiums.
It would also permit states to get waivers allowing insurers to charge higher premiums based on a person's ''health status,'' if a state had a program to help pay the largest claims or had a high-risk pool where sick people could purchase health insurance.
To qualify for a waiver, a state would have to explain how it would advance at least one of five purposes: reducing average premiums for consumers; increasing the number of people with coverage; stabilizing the insurance market; increasing the choice of health plans; or stabilizing premiums for people with pre-existing conditions.
The House Freedom Caucus members, acutely aware that the White House and Republican colleagues blamed them for the failure of the earlier bill, were eager to shift the blame to more moderate members who may now reject the measure. And the biggest conservative pressure groups off Capitol Hill -- Heritage Action, Club for Growth and Freedom Partners -- dropped their opposition to the measure, known as the American Health Care Act.
''Over the past couple of months, House conservatives have worked tirelessly to improve the American Health Care Act to make it better for the American people,'' Alyssa Farah, a spokeswoman for the House Freedom Caucus, said in a prepared statement. Because of those changes, she added, ''the House Freedom Caucus has taken an official position in support of the current proposal.''
The group agrees to take an official position when 80 percent of its roughly three dozen members agree.
But what is good for the most conservative corners of the House is not necessarily going to please their colleagues, including the dozens who had already rejected a less-conservative version of the bill. Republican senators had been equally wary. ''I think a better approach is to stabilize the insurance pool,'' said Senator Bill Cassidy, Republican of Louisiana.
In effect, the more that the bill changes to get through the House, the less chance it has of surviving in the Senate, both because of Senate rules and because the provisions that conservatives have excised are popular.
A recent ABC News/Washington Post poll found that 62 percent of respondents supported nationwide minimum insurance coverage standards and just 33 percent would leave such standards up to the states. Among Republicans, 54 percent supported a nationwide standard for coverage of pre-existing conditions.
Republican senators from states that have expanded Medicaid under the Affordable Care Act said the new House bill did nothing to ease their concerns about the deep cuts to Medicaid that remain in the legislation.
''There's still going to be some of us here in the Senate who would like to weigh in, particularly on Medicaid expansion, which is not part of the bill,'' said Senator Rob Portman, Republican of Ohio.
Democrats assailed the latest proposal, saying it did nothing to help those who would be left without coverage under the repeal bill. By 2026, the number of uninsured people would be 24 million higher than under the current law, according to the nonpartisan Congressional Budget Office.
Democrats denounced one part of the new proposal that, they said, would protect health insurance for members of Congress. This provision, they said, guarantees that lawmakers would not lose ''essential health benefits'' and could not be charged higher premiums because of their health status. The group that helps elect House Democrats immediately unleashed internet ads in 30 Republican-held districts railing against the carve-out.
''The monstrous immorality of Trumpcare is perfectly encapsulated in House Republicans' plan to exempt their own health coverage from the damage it will do to everyone else,'' said the House Democratic leader, Nancy Pelosi of California.
Mr. MacArthur backed away from this part of his proposal on Wednesday. ''Congressman MacArthur does not believe members of Congress or their staff should receive special treatment and is working with House leadership to make absolutely clear that members of Congress and staff are subject to the same rules, provisions and protections as all other Americans,'' a spokeswoman said.
Mr. Trump, seeking a major legislative victory in his first 100 days in office, has been pressing hard to get a floor vote on a measure to repeal Mr. Obama's signature health care law and to fulfill a campaign promise of most Republicans for the better part of a decade.
Vice President Mike Pence and other White House staff have been feverishly trying to get the most conservative members to support a bill, even one that is not viable in the Senate, and without the input of many moderate members.
But the effort may be creating momentum.
''The key is, all of us recognize we and the president made campaign promises to repeal and replace Obamacare,'' said Representative Chris Collins, Republican of New York and a top Trump ally. ''We, as a team, all recognize we need to get to yes.'' He added, ''I am guardedly optimistic.''
Speaker Paul D. Ryan said Wednesday that a new bill could come to the floor at some point if sufficient support surfaced. ''We'll vote on it when we get the votes,'' he said.
As Republican leaders maneuvered toward a vote to repeal the Affordable Care Act, they were working to assure Democrats that the government would continue to subsidize out-of-pocket expenses for people buying insurance through the law's online marketplaces. Democrats have threatened to hold up legislation to keep the government funded past Friday unless they get guarantees that the so-called cost-sharing reductions would continue.
House Republicans had successfully sued the Obama administration to stop the payments, arguing that the administration was illegally spending money that Congress had not explicitly appropriated. By Wednesday afternoon, Democrats appeared convinced that the money would keep flowing, a significant promise that should help reassure insurance companies as they decide whether to offer policies on the marketplaces in 2018.
Ms. Pelosi neared a declaration of victory on that front, and on efforts to block funding this year for Mr. Trump's promised wall on the Mexican border.
''Our major concerns in these negotiations have been about funding for the wall and uncertainty about the CSR payments crucial to the stability of the marketplaces under the Affordable Care Act,'' she said. ''We've now made progress on both of these fronts.''
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December 10, 2015 Thursday
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Rubio Measure Delivers a Blow to Health Law
BYLINE: By ROBERT PEAR
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WASHINGTON -- A little-noticed health care provision slipped into a giant spending law last year has tangled up the Obama administration, sent tremors through health insurance markets and rattled confidence in the durability of President Obama's signature health law.
The attack stems from two years of effort by Senator Marco Rubio and others in Congress to undermine a key financing mechanism in the law. So for all the Republican talk about dismantling the Affordable Care Act, one Republican presidential hopeful has actually done something toward achieving that goal.
Mr. Rubio's efforts against the so-called risk corridor provision of the health law have hardly risen to the forefront of the race for the Republican presidential nomination, but his plan limiting how much the government can spend to protect insurance companies against financial losses has shown the effectiveness of quiet legislative sabotage.
The risk corridors were intended to help some insurance companies if they ended up with too many new sick people on their rolls and too little cash from premiums to cover their medical bills in the first three years under the health law. But because of Mr. Rubio's efforts, the administration says it will pay only 13 percent of what insurance companies were expecting to receive this year. The payments were supposed to help insurers cope with the risks they assumed when they decided to participate in the law's new insurance marketplaces.
Mr. Rubio's talking point is bumper-sticker ready. The payments, he says, are ''a taxpayer-funded bailout for insurance companies.'' But without them, insurers say, many consumers will face higher premiums and may have to scramble for other coverage. Already, some insurers have shut down over the unexpected shortfall.
''Risk corridors have become a political football,'' said Dawn H. Bonder, the president and chief executive of Health Republic of Oregon, an insurance co-op that announced in October it would close its doors after learning that it would receive only $995,000 of the $7.9 million it had expected from the government. ''We were stable, had a growing membership and could have been successful if we had received those payments. We relied on the payments in pricing our plans, but the government reneged on its promise. I am disgusted.''
Blue Cross and Blue Shield executives have warned the administration and Congress that eliminating the federal payments could have a devastating impact on insurance markets.
Twelve of the 23 nonprofit insurance cooperatives created under the law have failed, disrupting coverage for more than 700,000 people, and co-op executives like Ms. Bonder have angrily cited the sharp reduction in federal payments as a factor in their demise.
But Mr. Rubio is pressing forward, demanding a provision in the final spending bill now under negotiation that continues the current risk corridor restrictions, or even eliminates the program altogether. That enormous spending bill is being worked out as Congress slides toward a deadline of Friday, when much of the federal government's funding runs out.
''If you want to be involved in the exchanges and you lose money, the American taxpayer should not have to bail you out,'' Mr. Rubio said on the Senate floor on Thursday.
A White House spokeswoman, Katie Hill, declined to offer the administration's position on proposals that she said were still theoretical. ''We are not going to weigh in on the possible inclusion of proposals floated by members of Congress'' in potential legislation, she said.
Congress established the program in 2010 to protect insurers against the uncertainties they faced in setting the level of insurance premiums when they did not know who would sign up for coverage under the Affordable Care Act. Under the law, the federal government shares risk with insurers, limiting their gains and losses on insurance sold in the public marketplaces from 2014 through 2016. If consumer payments to an insurer exceed the company's medical expenses by a certain amount, the insurer pays some of that profit to the government. But if premium payments fall short of medical expenditures by a certain amount, the insurer is eligible for payments from the government.
The hope was that payments into the program would be in balance with payments out, shielding taxpayers from responsibility.
Mr. Rubio latched on to the issue in late 2013, recognizing not only the importance of risk corridors to the operation of the Affordable Care Act but also the political potency of a program he labeled crony capitalism -- putting taxpayers ''on the hook for Washington's mistakes,'' as he said when he reintroduced his risk corridor bill in January.
The ''bailouts'' of big banks and other financial firms during the economic crisis of 2008 and the rescue of the Big Three automakers that year and the next remain politically unpopular.
Then the numbers rolled in from the insurance exchanges' first year of operation: Losses were so steep that insurance-company requests for risk corridor payments were $2.9 billion, compared with only $362 million paid into the program by profitable plans.
Mr. Rubio says he ''saved taxpayers $2.5 billion'' -- the difference between those two amounts -- because his measure prevented the government from using other sources of money for the risk corridor payments.
The administration has repeatedly told insurers that it will explore other funding sources to keep its commitment to companies losing money in the exchanges, but Mr. Rubio effectively tied the hands of federal health officials this year.
Like many other observers of the health law, the Obama administration initially failed to appreciate the impact of the Rubio restrictions. Kevin J. Counihan, the chief executive of the federal insurance marketplace, told state officials in July that money collected from insurance companies would be ''sufficient to pay for all risk corridor payments.'' More recently, the administration consoled insurers by telling them that it would make additional risk corridor payments from money collected in 2015 and 2016.
But in a new report, the credit ratings agency Standard & Poor's says that money will not be there.
Mr. Rubio says Mr. Obama compounded his problems by diverting risk corridor funds to quell a 2013 furor over canceled insurance policies. That year, the president announced that states could let insurers renew canceled plans and continue coverage for several years even if those policies did not meet the requirements of the federal health law.
Insurers were shocked by the sudden change. They had set 2014 premiums on the assumption that healthy people with old insurance policies would move into the new marketplace, but Mr. Obama allowed many of them to stay out. In a letter to state insurance commissioners in November 2013, the administration said ''the risk corridor program should help ameliorate unanticipated changes in premium revenue.''
Five days later, Mr. Rubio introduced his bill to kill the risk corridor program.
Insurers now are lobbying to get more of the money they say they were promised, or to get relief in some other form.
Mr. Rubio has highlighted the role of Marilyn B. Tavenner, the former Obama administration official in charge of rolling out HealthCare.gov who is now president of the trade group America's Health Insurance Plans.
''The former Obama administration official who led the rollout of Obamacare's exchanges and now runs the health insurance lobby is working with her White House allies to secure a new bailout by providing more funding for the law's risk corridor program,'' Mr. Rubio said last week.
Clare Krusing, a spokeswoman for the insurance group, said the federal payments were not a bailout for the industry, but a way of stabilizing the market and thus protecting consumers. ''When health plans cannot rely on the government to meet its obligations,'' she said, ''individuals and families are harmed.''
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January 5, 2017 Thursday
The New York Times on the Web
The Parliamentary Tactic That Could Obliterate Obamacare
BYLINE: By ROBERT PEAR
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WASHINGTON -- Republicans hope to repeal major parts of the Affordable Care Act using an expedited procedure known as budget reconciliation.
The process is sometimes called arcane, but it has been used often in the past 35 years to write some of the nation's most important laws. ''Reconciliation is probably the most potent budget enforcement tool available to Congress for a large portion of the budget,'' the Congressional Research Service, a nonpartisan arm of Congress, has said.
Here is a primer.
Q. What is the budget reconciliation process?
A. It is a way for Congress to speed action on legislation that changes taxes or spending, especially spending for entitlement programs like Medicare and Medicaid. Although conceived primarily as a way to reduce federal budget deficits, it has also been used to cut taxes and to create programs that increase spending -- changes that can raise deficits.
In the Senate, a reconciliation bill can ordinarily be passed with a simple majority. For other bills, a 60-vote majority is often needed to limit debate and move to a final vote.
Q. Why is it called reconciliation?
A. The term originated in the Congressional Budget and Impoundment Control Act of 1974, which was intended to give Congress more control over the budget process by allowing lawmakers to set overall levels of spending and revenue.
The process begins with a budget blueprint, a resolution that guides Congress but is not presented to the president for a signature or veto. It recommends federal revenue, deficit, debt and spending levels in areas like defense, energy, education and health care.
The resolution may direct one or more committees to develop legislation to achieve specified budgetary results. By adopting these proposals, Congress can change existing laws so that actual revenue and spending are brought into line with -- reconciled with -- policies in the budget resolution.
Q. How has reconciliation been used?
A. Since 1980, Congress has completed action on 24 budget reconciliation bills. Twenty became law. Four were vetoed.
The Omnibus Budget Reconciliation Act of 1981 was a vehicle for much of the ''Reagan revolution.'' It squeezed savings out of Social Security, Medicare, Medicaid, food stamps, the school lunch program, farm subsidies, student loans, welfare and jobless benefits, among many other programs.
In 1996, Congress reversed six decades of social welfare policy, eliminating the individual entitlement to cash assistance for the nation's poorest children and giving each state a lump sum of federal money with vast discretion over its use. Those changes were made in a reconciliation bill, pushed by Republicans but signed by President Bill Clinton.
Congress reduced deficits with another reconciliation bill, the Balanced Budget Act of 1997. That law also created the Children's Health Insurance Program, primarily for uninsured children in low-income families. On the same day in 1997, Mr. Clinton signed a separate reconciliation bill that cut taxes.
The Bush tax cuts were adopted in reconciliation bills signed by President George W. Bush in 2001 and 2003.
On several occasions, Congress has increased assistance to low-income working families by increasing the earned-income tax credit in reconciliation bills.
Congress also made changes to the Affordable Care Act in a reconciliation bill passed immediately after President Obama signed the health care overhaul in 2010. Later, when Republicans controlled both houses of Congress, they passed a reconciliation bill to eviscerate the Affordable Care Act, but Mr. Obama vetoed the bill in January 2016.
Republicans say that measure will provide a template or starting point for their efforts to undo the health care law this year, with support from President-elect Donald J. Trump, who calls the law ''an absolute disaster.''
Q. How does the reconciliation process work in the Senate?
A. In the House, leaders of the majority party can usually control what happens if their members stick together. In the Senate, by contrast, one member or a handful of senators can often derail the leaders' plans. The reconciliation process enhances the power of the majority party and its leaders. Senate debate on a reconciliation bill is normally limited to 20 hours, so it cannot be filibustered on the Senate floor.
The Senate has a special rule to prevent abuse of the budget reconciliation process. The rule, named for former Senator Robert C. Byrd, Democrat of West Virginia, generally bars use of the procedure to consider legislation that has no effect on spending, taxes and deficits. The Senate parliamentarian normally decides whether particular provisions violate the Byrd rule, but the Senate can waive the rule with a 60-vote majority.
Q. What does this mean for the Affordable Care Act?
A. Republicans hope to use the fast-track procedure of budget reconciliation to repeal or nullify provisions of the law that affect spending and taxes. They could, for example, eliminate penalties imposed on people who go without insurance and on larger employers who do not offer coverage to employees.
They could use a reconciliation bill to eliminate tens of billions of dollars provided each year to states that have expanded eligibility for Medicaid. And they could use it to repeal subsidies for private health insurance coverage obtained through the public marketplaces known as exchanges.
Republicans could also repeal a number of taxes and fees imposed on certain high-income people and on health insurers and manufacturers of brand-name prescription drugs and medical devices: tax increases that help offset the cost of the insurance coverage expansions.
Those provisions were all rolled back in the reconciliation bill Mr. Obama vetoed last January. That bill did not touch insurance market standards established in the Affordable Care Act, which do not directly cost the government money or raise taxes. The standards stipulate, for example, that insurers cannot deny coverage or charge higher premiums because of a person's pre-existing conditions. Insurers must allow parents to keep children on their policies until the age of 26, and they cannot charge women higher rates than men, as they often did in the past.
Such provisions are politically popular, but it is not clear how they could remain in force without the coverage expansions that help insurers afford such regulations. Without an effective requirement for people to carry insurance, and without subsidies, supporters of the health law say many healthy people would go without coverage, knowing they could obtain it if they became ill and needed it.
Democrats say they will fight to preserve the law after Mr. Obama leaves office. Recent history shows that lobbying and public pressure can sometimes make a difference, altering the votes of individual lawmakers and changing the contents of a reconciliation bill.
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January 29, 2014 Wednesday
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Comparing Obamacare to Its Alternative
BYLINE: By EZEKIEL J. EMANUEL
SECTION: Section ; Column 0; National Desk; CONTRIBUTING OP-ED WRITER; Pg.
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FROM the moment the ink dried on March 23, 2010, Republicans said they intended to ''repeal and replace'' the Affordable Care Act. They have voted more than 40 times to wipe the law from the books. But Republicans have never gotten around to describing, in detail, the set of policies they believe should replace Obamacare. That is, until yesterday.
After nearly four years, we finally have a Republican counterproposal: the Patient Choice, Affordability, Responsibility and Empowerment (or Patient CARE) Act.
Senators Tom Coburn, Richard Burr and Orrin Hatch deserve credit for developing this plan. Putting together a proposal to reform the American health care system is hard and politically courageous. And while it is lacking in important details, this plan contains some interesting ideas that might have enabled bipartisan compromises had they been offered in 2009, when I was a health care adviser to the Obama administration and the Affordable Care Act was being debated. For instance, the plan would shift many low-income adults from Medicaid to subsidized private insurance. There are some Democrats who could certainly have supported such a proposal, if it had been offered as part of a deal to enact a bipartisan bill.
Despite all the heated rhetoric from Republicans about Obamacare laying ruin to America, the plan would actually keep some of the law's key provisions. It would preserve some subsidies for lower-income people to buy private insurance, though it would change the way they are calculated. Those $700 billion worth of Medicare savings Mitt Romney denounced during the 2012 campaign? Republicans would keep them. Allowing young adults to stay on their parents' plan until age 26? Republicans would keep that, too. And the ban on lifetime insurance caps, so people with very expensive diseases don't lose insurance? Republicans wouldn't touch it.
But in other crucial ways, the Republican plan is different. First, Obamacare's absolute ban on withholding coverage from people with pre-existing conditions would be rolled back. Those who remained continuously insured would stay protected, so they couldn't be charged higher rates or be excluded entirely. But if their insurance lapsed, health insurance companies could charge more or refuse to cover them.
Second, it would shrink the Medicaid expansion. Pregnant women, children and families below the poverty line would still be eligible, but childless adults would not. States would be given a fixed amount per person enrolled in Medicaid to reduce spending.
Third, the Republicans would provide tax credits for people to buy insurance, but only for families earning up to $70,650 per year. (The Affordable Care Act's subsidies go to families earning up to $94,200.) And employees of large companies, even if those companies did not offer health insurance, would be exempt, regardless of income.
The largest difference is in cost control. Currently, employer-sponsored health insurance is tax free; the Republican plan would make employees pay income tax on at least 35 percent of what their company pays for their plan. The idea is to make patients pay more for their coverage, giving them an incentive to choose cheaper health insurance plans with more deductibles and co-payments, which, in turn, would encourage them to shop around for cheaper tests and treatments and forgo unnecessary ones.
On a more individual level, this is what the Republican plan means: If you are one of the 150 million Americans who get their health insurance through an employer-sponsored plan, get ready for a big tax increase. For a family in the 28 percent tax bracket (earning around $150,000 per year), according to my calculations, it would add up to about $1,470 per year.
Here's how you get that number: In 2013, the average employer-sponsored insurance plan cost $16,351 for a family of four. On average, employers pay 72 percent of that premium, or $11,786. The Republican plan taxes 35 percent of the employer contribution, meaning that an additional $4,125 would be counted as income and subject to both payroll and income taxes. So that family would pay about $1,154 in income taxes and $316 in payroll taxes -- $1,470 per year. Obviously, people would pay even more if their health-insurance premium was higher, if they were in a higher tax bracket, or if their state had an income tax.
People who don't get insurance through their employer would also be likely to pay more. The Republican plan would provide the unemployed, people in the individual market and those working for small businesses that don't provide health insurance a tax credit to buy private insurance. But the credit increases only by age, not by need -- which means people with lower incomes would pay much more than they would under Obamacare. For example, under the Republican plan, a 30-year-old man living in New York City earning $35,000 a year would pay the full price of insurance, roughly $4,383 for a typical plan. Under Obamacare, he would pay $3,325. A 30-year-old earning $25,000 would get a $1,560 tax credit and pay roughly $2,823 under the Republican plan, but pay only $1,728 under Obamacare.
In addition, the proposed plan would take us back to the old days when insurance companies could charge women more than men for the same health plan. And older people would also be penalized. Under the Affordable Care Act, insurance companies are allowed to charge 64-year-olds only three times what they charge 21-year-olds. But the Republican plan allows insurance companies to charge 64-year-olds five times more. So a 64-year-old individual could pay as much as $21,900 for a plan that costs a 21-year-old only $4,380.
The plan would bring back many insurance company shenanigans. For instance, the decision to roll back the ban on excluding those with pre-existing conditions sounds O.K. in theory: ''individuals moving from one health plan to another -- regardless of whether it was in the individual, small group, or large employer markets -- could not be medically underwritten,'' meaning charged higher premiums based on a disease, and ''denied a plan based on a pre-existing condition if they were continuously enrolled in a health plan.'' So if you lose your job and therefore your employer-sponsored health insurance, you would not be excluded for a pre-existing condition if you immediately bought your own insurance. But if there were a gap in coverage, insurance companies could deny you coverage.
What if the paperwork you filled out is ''lost''? The history of insurance companies' tricks for denying coverage to high-cost patients -- like revoking the insurance of a cancer patient who failed to disclose that she had back problems -- does not inspire confidence.
Finally, there is the issue of prevention. The Affordable Care Act made preventive services free. To save money, Republicans want to reverse that, so that Americans will behave like cost-conscious consumers -- getting their blood tests at a cheaper laboratory or their CT scans at the cheaper imaging center. The problem is that mountains of evidence show that when patients have to pay, prevention is the first thing to go, in part because people aren't suffering pain or other symptoms, and the benefits of preventive services are typically years away. Saving money by cutting back these services makes no economic sense in the long-term.
There are many other problematic things the Republican plan does, like eliminate the health law's taxes on health insurance, drug and device companies; allow insurance companies to sell plans that don't cover maternity, mental health or other types of care; and allow insurance companies to impose annual limits on benefits.
We finally got the ''replace'' part of the Republicans' pledge to ''repeal and replace'' the Affordable Care Act. Now that Americans have the chance to examine the alternative, it might help them see the advantages of Obamacare.
URL: http://www.nytimes.com/2014/01/29/opinion/comparing-obamacare-to-its-alternative.html
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December 5, 2011 Monday
Labor Department Seeks Tougher Rules on 'Multiple-Employer' Plans
BYLINE: BRUCE JAPSEN
SECTION: HEALTH
LENGTH: 830 words
HIGHLIGHT: The federal agency says it wants more authority to crack down on insurance plans that take advantage of small businesses and their employees.
Federal officials hope to crack down more effectively on operators of "multiple employer" health plans that have defrauded small businesses and their workers of hundreds of millions of dollars, often leaving them stuck with unpaid medical bills, according to new rules proposed Monday by the Obama administration under the health care legislation.
Known as Multiple Employer Welfare Arrangements, or MEWAs, such plans have a checkered history under operators who used federal law in the past as a shield from state insurance investigators. The plans are set up for small businesses to provide their workers with lower cost coverage by pooling premium contributions from the employers and workers together for benefits that are paid from the arrangement.
Yet an unintended consequence of the Employee Retirement Income Security Act of 1974, which has restricted states from regulating multiple employer arrangements, allowed these plans to dodge state insurance examiners, often after high fees were paid and money was then unavailable to pay medical claims and other benefits.
In the last two decades, the Department of Labor said it had initiated 800 civil and more than 300 criminal investigations, but often had been unable to prevent the operators of the plans from draining assets of the plans through a variety of schemes that included "excessive administrative fees or outright embezzlement resulting in harm to participants and their families," the agency said in a statement.
Under the rules proposed Monday, the Secretary of Labor would have the authority to issue a "cease and desist order" when federal officials believe fraud is taking place. The secretary can also freeze assets, stop marketing and certain other business practices.
"For the first time, the federal government has some tools that we have never had to get at these MEWAS early before the money is gone and everybody is left in the lurch," said Phyllis C Borzi, assistant secretary of labor for the Employee Benefits Security Administration. "Once we have these new tools, hopefully the losses will go down because we will be able to intervene before the money is gone."
There have been many high profile cases of defrauded MEWAs, like that of TRG Health Plan, which had more than 11,000 plan subscribers and operated in more than 40 states and left behind more than $17 million in unpaid medical claims when it was terminated 10 years ago. The labor department alleged TRG's operators diverted assets to accounts of an affiliated marketing firm, failed to charge adequate premiums and did not have sufficient assets to pay benefits.
Often, small employers, unions or trade associations will turn to a MEWA for affordable benefits because an insurance company will not cover those who may have an older population of workers or employees who might be in poor health. So analysts say operators of MEWAs bilked the most vulnerable of Americans in search of affordable coverage for themselves and their workers.
Take the National Writers Union, which turned to a MEWA known as Employers Mutual when their insurance carrier dramatically raised rates. The plan, based in Nevada, sold benefits to 22,000 policy holders and was unlicensed in states, claiming its structure did not require it to be licensed. The plan left behind more than $24 million in unpaid claims, a 2004 General Accounting Office report said.
"Whenever people are desperate for affordable coverage, they look for alternatives and unscrupulous individuals target those kinds of people," said Mila Kofman, the former superintendent of insurance for Maine who is professor at Georgetown University's Health Policy Institute. "Many have been hauled into federal court but the U.S. Department of Labor didn't have tools to act quickly."
Federal officials estimate more than 2 million Americans are enrolled in hundreds of MEWAs but they cannot be certain because they don't know.
Another crucial part of the proposed regulations are that MEWAs have to register with the Department of Labor before operating or be subject to various penalties. The lack of licensure or registration made MEWAs a fertile opportunity for frauds.
"We don't even know how many of these there are," Ms. Borzi said.
Following a 90-day public comment period, the proposed rules will become final, probably by mid-2012.
The insurance industry, which is not known for welcoming new regulations, welcomed the labor department's proposals.
"We are pleased the government is going to have these added powers," said Alissa Fox, senior vice president of the Blue Cross and Blue Shield Association. "These entities are avoiding oversight and harming consumers. It hurts consumers and we are concerned when consumers are being hurt by entities that are not going to be paying these bills."
Inspecting Your Insurance Premiums
Insurance Premiums Vary Widely Across States
Double-Digit Insurance Rate Increases Get More Scrutiny
The Debate Over Brokers' Fees
This Week's Health Industry News
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December 8, 2016 Thursday 00:00 EST
Harry Reid: Farewell, Fair Senate;
Opinion
BYLINE: HARRY REID
SECTION: OPINION
LENGTH: 879 words
HIGHLIGHT: Ending the ability to filibuster presidential nominations was the right thing to do, and I stand by it.
Washington - In my time in the Senate, I've served with 281 senators. I've rarely given advice unless asked. But since I am leaving the Senate floor for the final time, I have a few things to say.
To Republicans, I say recognize the difference between campaigning and governing, and beware of knee-jerk opposition to the accomplishments of the Obama era.
Despite the fact that your nominee lost the popular vote by nearly three million votes, your leaders have announced their intention to repeal the Affordable Care Act early in the next Congress, with no replacement. This is a dramatic misreading of your mandate. It will lead you into a quagmire that will cause pain for millions of Americans and bedevil you for the next four years.
Repealing Obamacare will take health insurance away from millions of Americans - as many as 30 million, by one recent estimate. It will raise premiums and throw health insurance markets into disarray. Public support for repeal is low, and support for repeal without a replacement is in the basement.
If you continue down this path, you will be letting your reflexive opposition to President Obama's legacy cloud your judgment. I was in the Senate when President George W. Bush misread his mandate and sought to privatize Social Security. His administration never recovered.
To Democrats, I say it has never been more important to stand up for the things we believe in. We are entering a new Gilded Age. Next year, a billionaire president who just settled a fraud suit for $25 million over his business exploits will be pushing tax cuts for the top 1 percent, supposedly in the name of populism.
Much of the responsibility for separating what is real and what is fake will fall on Democrats. We should ask ourselves: Do the choices we make about how we spend our time keep us in touch with what we believe in, and what is real in our own lives?
For me, one of those choices has been to spend as much time as possible with the people who know me and know where I came from: a town called Searchlight. In the more than three decades I've been in Washington, there have by my count been 136 various press correspondents' dinners. I've been to one. And I might hold the record for spending as little time at fund-raisers as possible; I am usually in and out of the door in 10 minutes or less.
One thing we fought for that's worth defending is a fairer, more open and more productive Senate. We changed the Senate rules to guarantee a president's nominees a simple-majority vote, and declared that a president's nominees should not be stymied with procedural hurdles and a requirement for supermajority votes. (Supreme Court nominations still have this requirement.)
We declared that the changes should apply regardless of which party was in the White House, because fair votes are what democracy is all about. I doubt any of us envisioned Donald J. Trump's becoming the first president to take office under the new rules. But what was fair for President Obama is fair for President Trump.
Moreover, the rule change has been a victory for those who want to see a functioning, open and transparent Senate. It allowed Mr. Obama's judicial nominees to receive the just consideration they deserved. Without the rule change, Republicans would have been able to hold open three seats on our nation's second highest court, the District of Columbia Circuit Court, until the next Republican administration. The judges we confirmed to those seats will loom large in the years to come. In 2014 alone, the Senate confirmed 89 Circuit and District Court judges, more than for any year in two decades.
The rule change was consistent with the history of the Senate, which has continually evolved when faced with new challenges. Historically, the only way to reject nominees to cabinet posts, which are not lifetime appointments, has been by a simple-majority vote. Moreover, the supermajority threshold for bills and nominations is not in the Constitution, nor was it in the original Senate rules.
From George Washington to George W. Bush, only 68 presidential nominees had been filibustered. Senate Republicans took obstruction to a new level, filibustering 79 of Mr. Obama's nominees in just four years. By removing such procedural ploys, the rule change puts the debate over nominees out in the open. Senators have to answer a simple question: Should a nominee be confirmed, or not? Nominees are now guaranteed a floor vote.
With Republicans holding a slim majority, Democrats have a fighting chance at winning every debate. To be sure, persuading a majority of the Senate to your side is harder than blocking a confirmation on a procedural vote. But it is also fairer.
When Democrats pick their fights next year, they can do so knowing that, win or lose, they will be debating in a Senate that we made more open and more transparent. If Democrats stand for what they believe in, they will find that trusting the courage of their convictions while out of power will empower them to accomplish great things when the pendulum swings back, as it always does.
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Harry Reid is a Democratic senator from Nevada and the departing Senate minority leader.
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January 14, 2017 Saturday 00:00 EST
The Optimism of Barack Obama;
Editorial
BYLINE: THE EDITORIAL BOARD
SECTION: OPINION; sunday
LENGTH: 936 words
HIGHLIGHT: Americans will miss both the character and eloquence of the president, who leaves a legacy of solid accomplishment despite bitter partisan opposition.
Barack Obama is leaving the White House with polls showing him to be one of the most popular presidents in recent decades. This makes sense. His achievements, not least pulling the nation back from the worst economic crisis since the Great Depression, have been remarkable - all the more so because they were bitterly opposed from the outset by Republicans who made it their top priority to ensure that his presidency would fail.
Many Americans celebrated the election of the first African-American president as a welcome milestone in the history of a nation conceived in slavery and afflicted by institutional racism. Yet the bigotry that president-elect Donald Trump capitalized on during his run for office confirmed a point that Mr. Obama himself made from the start: that simply electing a black president would not magically dispel the prejudices that have dogged the country since its inception. Even now, these stubborn biases and beliefs, amplified by a divisive and hostile campaign that appealed not to people's better instincts but their worst, have blinded many Americans to their own good fortune, fortune that flowed from policies set in motion by this president.
That story begins on Inauguration Day in 2009. That's when Mr. Obama inherited a ravaged economy that was rapidly shedding jobs and forcing millions of people from their homes. The Obama stimulus, which staved off a 1930s-vintage economic collapse by pumping money into infrastructure, transportation and other areas, passed the House without a single Republican vote. Republican gospel holds that government spending does not create jobs or boost employment. The stimulus did both -preserving orcreating an average of 1.6 millions jobs a year for four years. (A timely federal investment in General Motors and Chrysler, both pushed to the brink during the recession, achieved similarly salutary results, preserving more than a million jobs.)
Mr. Obama's opponents have had trouble accepting that any of this actually happened. They have not learned the simple truth - a truth clear in the New Deal and just as clear now - that timely and significant federal investment can make a real difference in people's lives. Or accepted that compassionate and well-designed government programs can do the same. Driven by ideology or envy, or maybe both, Republican leaders have now pounced upon the demonstrably successful Affordable Care Act of 2010, a law that has improved the way medical care is delivered in the United States, providing affordable care for millions and driving the percentage of Americans without insurance to a record low9.1 percent in 2015. Despite the law's clear successes, Mr. Trump and Republican congressional leaders have nevertheless declared it a failure, hoping to justify a repeal that would roban estimated 22 million peopleof health insurance. The point of following this destructive course can only be to destroy a central Obama legacy - even though doing so will drive up costs and cause havoc in the lives of the newly uninsured.
With no help from Congress, Mr. Obama has also managed to make progress on issues where nobody gave him much of a chance, notably climate change, which both he and his secretary of state, John Kerry, placed very near the top of their to-do list. Against heavy odds, Mr. Obama first managed to persuade the Chinese to join the effort. This demolished the critics' argument that he was asking America to do all the heavy lifting. It also made possible the Paris agreement in December 2015, in which 195 nations agreed on a plan that they hope will reduce greenhouse gases that are warming the atmosphere and threatening the viability of the planet itself.
Americans will miss Mr. Obama's negotiating skills on tough issues and the dignity and character that he and his family brought to the White House. Beyond that, they will also miss an impassioned speaker whose eloquence ranks with that of Abraham Lincoln. The way he has defended the founding precepts of the United States while also arguing that those precepts have to be broadened to achieve a new inclusiveness has been especially striking, as have his remarks delivered at moments of national tragedy.
His 2015 eulogy in Charleston, S.C., after a Confederate flag-waving white supremacist slaughtered nine African-American parishioners at Emanuel African Methodist Episcopal Church, was redolent with history. As always, he viewed the horror through the prism of a seemingly innate optimism about the country's ability to set aside hatred and move toward a more perfect union.
Mr. Obama never would have gained the office without that unflagging optimism, which inspired a generation of young voters who saw in him a new kind of leader. So it seemed fitting that he would end his farewell address in Chicago on Tuesday with them in mind:
"Let me tell you, this generation coming up - unselfish, altruistic, creative, patriotic - I've seen you in every corner of the country. You believe in a fair and just and inclusive America; you know that constant change has been America's hallmark, that it's not something to fear but something to embrace; you are willing to carry this hard work of democracy forward. You'll soon outnumber any of us, and I believe as a result the future is in good hands."
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President Obama's Farewell Address: Full Video and Text
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January 3, 2017 Tuesday 00:00 EST
Trump and Senate Move Quickly to Repeal Affordable Care Act;
Transition Briefing
BYLINE: CHARLIE SAVAGE, MAGGIE HABERMAN and RICHARD PÉREZ-PEÑA
SECTION: US; politics
LENGTH: 2101 words
HIGHLIGHT: President-elect Donald J. Trump took to Twitter to denounce President Obama's signature domestic achievement, as Senate Republicans disclosed legislation to dismantle it.
" President-elect Donald J. Trump and Senate Republicans moved quickly to begin dismantling the Affordable Care Act.
" Hillary and Bill Clinton will attend Mr. Trump's swearing in on Jan. 20. Awkward.
" A White House job for Omarosa Manigault, the reality TV star.
Trump and Republicans take measures to gut the Affordable Care Act
That didn't take long.
Before the new members could even be sworn in, Senate Republicans revealed the parliamentary language that congressional Republicans will use to dismantle Mr. Obama's signature domestic achievement, the Affordable Care Act, without fear of a filibuster by Democrats in the coming months.
The instructions are simple and vague: The Senate Finance and the Health Committees, along with the House Ways and Means and Energy and Commerce Committees, have until Jan. 27 to "report changes in laws" within their jurisdiction "to reduce the deficit by not less than $1,000,000,000 for the period of fiscal years 2017 through 2026."
Translation: The Senate and House have barely more than three weeks to complete legislation that reduces the deficit slightly over the next decade and, in the process, guts the Affordable Care Act beyond repair.
Debate will begin on the Senate floor on Wednesday, bypassing the Senate Budget Committee to speed passage.
Mr. Trump took to Twitter on Tuesday to amplify the message.
The rate increases, revealed in October, had long been predicted in Arizona, where many insurers had announced plans to drop out of the marketplace, and they affect a small fraction of residents. But they fit the Republican narrative that the law has made health care worse for Americans, despite the fact that it has provided coverage to tens of millions of previously uninsured people.
Left unsaid: What will happen to more than 20 million Americans now insured under the Affordable Care Act, or to the 27 percent of Americans with pre-existing medical conditions who, under the health care act, cannot be denied coverage by insurance companies?
The Clintons will attend Trump's swearing in
She called Mr. Trump "unfit" to be the commander-in-chief. He called her a "nasty woman." But Mrs.Clinton will be attending Mr. Trump's inauguration, along with her husband.
It is customary for former presidents and first ladies to observe the peaceful transfer of power in person. Former President George W. Bush and his wife, Laura, will also be in Washington on Jan. 20 for the inaugural festivities.
Not since Al Gore shared the stage with Mr. Bush in 2001 has such an awkward pairing occurred at an inauguration. Mr. Gore won the popular vote in 2000 and only conceded the loss after the United States Supreme Court intervened to stop a recount in Florida. Mrs. Clinton's loss was less contested, but her victory total in the popular vote, by 2,864,974 million votes, dwarfed Mr. Gore's 543,895 margin in 2000. Mrs. Clinton's total popular vote was the largest for a losing candidate since 1876.
A White House job for Omarosa
Omarosa Manigault, an original series star of Mr. Trump's reality television show "The Apprentice," is expected to have a senior role in the Office of Public Engagement at the White House, a senior transition official said.
Ms. Manigault has no government experience. But she has been deeply loyal to Mr. Trump, and was among his few well-known black supporters during the campaign.
Deval Patrick to Senate: Don't make Jeff Sessions attorney general
Deval Patrick, the former Massachusetts governor, made a forceful plea on Tuesday for the Senate not to confirm Senator Jeff Sessions of Alabama as attorney general, recalling when the two men were on opposite sides of a racially tinged case three decades ago, and calling Mr. Sessions "the wrong person to place in charge of our justice system."
In 1985, Mr. Sessions, then a federal prosecutor in Alabama, brought criminal charges against three black voting rights activists for helping older black voters, many of whom had been barred from voting for most of their lives, fill out absentee ballots. One of the lawyers for the defense in that case was Mr. Patrick, who was working for the NAACP Legal Defense and Educational Fund, and later became head of the Justice Department's civil rights division under President Bill Clinton.
A jury acquitted the defendants.
In a letter sent Tuesday to the Senate Judiciary Committee, Mr. Patrick, who is black, wrote that Mr. Sessions relied on a baseless theory - that helping someone to vote is illegal - and did so selectively, targeting black people who had helped black voters. Mr. Patrick is a Democrat, and Mr. Sessions, nominated by Mr. Trump to lead the Justice Department, is a Republican.
"To use prosecutorial discretion to attempt to criminalize voter assistance is wrong and should be disqualifying for any aspirant to the nation's highest law enforcement post," he wrote. And while absentee ballots were in widespread use, "Mr. Sessions investigated only the use by black voters and only where white incumbents were losing political ground."
Trump to Obama: No more releases from Guantánamo
It has been a busy day for the president-elect on Twitter, but he took the time to prepare his supporters for a late flurry of transfers from Guantánamo Bay that Mr. Obama plans in the coming days.
The New York Times reported last month that the Obama administration had deals to transfer about 18 of the remaining 59 detainees before Mr. Obama leaves office on Jan. 20. If all goes as planned, most would go to three gulf nations - Oman, Saudi Arabia and the United Arab Emirates - and be placed in custodial rehabilitation programs. One would go to Italy.
All of the men set to leave the prison are on a list of those recommended for transfer, if security conditions can be met in the receiving country, by six United States security agencies. Most have been held for about 14 years in wartime detention without trial and are from unstable countries, like Yemen, which complicated efforts to find a place to send them.
While Mr. Obama failed to fulfill his vow to close the Guantánamo prison, he refused to place any new detainees there and has whittled its population from the 242 prisoners he inherited from the administration of President George W. Bush.
Mr. Trump has vowed to keep the prison open and "load it up with some bad dudes."
Civil rights activists occupy Sessions's office
The protest season is beginning even before the swearing in.
Officials of the N.A.A.C.P. and its Alabama chapter occupied Mr. Sessions's office in Mobile, Ala., demanding that the senator withdraw his name from consideration to be the next attorney general.
Trump picks U.S. trade representative
Mr. Trump, whose campaign for the White House was centered on an anti-trade and anti-globalization message, on Tuesday selected Robert E. Lighthizer, an international trade lawyer who has argued in favor of protectionist policies in some cases, as his United States trade representative.
In Mr. Lighthizer, a top trade attorney representing multinational companies at Skadden, Arps, Slate, Meagher & Flom who was a trade official for Ronald Reagan, Mr. Trump has selected a seasoned negotiator who is intimately familiar with the benefits of global agreements. But Mr. Lighthizer has also been outspoken in pointing out their potential harm to United States interests. It is not clear what role he will play in the Trump administration now that the president-elect has created a White House National Trade Council and placed Peter Navarro, an economist who is a leading critic of China, at its helm.
Mr. Lighthizer has also been harshly critical of China, and in a 2010 Op-Ed article in The New York Times, he presaged some of Mr. Trump's talk on trade.
"Given the Tea Party's desire to restore America's greatness, it will push Washington to stand up to China and re-establish American pre-eminence, even at the cost of the country's free-trade record," Mr. Lighthizer wrote.
At the same time, he has lobbied on behalf of major American corporations to pry open foreign markets.
In response to the announcement, Senator Orrin G. Hatch, the chairman of the Senate Finance Committee and an ardent free-trade supporter, appears to have given up on the kinds of expansive multilateral trade deals, like the Trans-Pacific Partnership, that he once championed. What is left of the free-trade caucus now appears content with small deals with individual countries.
"The incoming Trump administration has a unique opportunity to pursue new, bilateral trade pacts of the highest caliber that can be submitted to Congress for an up-or-down vote with no amendments," Mr. Hatch wrote.
And speaking of trade ...
The president-elect, who targeted Boeing on its Air Force One upgrade, Lockheed on its advanced military fighter jet and, of course, Carrier on its Indianapolis furnace plant, seems to have taken a shine to General Motors.
In fact, it was President Obama who saved the Lordstown, Ohio, G.M. plant in 2009, with the auto bailout, visiting the factory that year to take a Chevrolet Cruze for a spin on the plant floor.
And G.M. has now responded:
G.M. imports hatchback versions of the Cruze from a factory in Ramos Arizpe, Mexico, which was only a small percentage of the 172,000 Cruzes sold through November, said Patrick Morrissey, a spokesman.
Obama's mission: Save the Affordable Care Act
With less than three weeks left before he leaves office, Mr. Obama has a more immediate concern in Congress: how to prevent Mr. Trump and Republicans from rolling back his domestic accomplishments, especially the Affordable Care Act.
Mr. Obama, who returned on Monday from a two-week vacation in Hawaii, plans to make a rare visit to Capitol Hill on Wednesday morning to huddle privately with House and Senate Democrats and discuss how to thwart the coming Republican assault on his legacy.
Democrats are strategizing about the best way to block the repeal of the health care law, as well as attempts to cut Medicare or Medicaid, and Mr. Obama has made it clear that he will use his remaining days in the White House to secure as many of his priorities as possible.
Mr. Pence will make a return to the Capitol - where he served for many years as a House member from Indiana - on Wednesday. He will be there to "discuss next steps to repeal and replace #Obamacare," Speaker Paul D. Ryan said on Monday on Twitter.
Bipartisan letter to Trump: Sell your businesses
A handful of Republicans - including several former governors and members of Congress - have joined with liberal ethics activists in pressing Mr. Trump to sell his business assets to prevent White House conflicts that could be "seriously damaging" to the presidency.
The letter sent to Mr. Trump includes the signatures of two former Republican governors, five former Republican members of the House and a collection of prominent ethicists, including Peter Schweizer, the editor at large of Breitbart and the author of "Clinton Cash," a book that criticized Hillary Clinton's connections to the Clinton Foundation.
In a number of cases, the Republicans who signed the letter have been critics of Mr. Trump since before the election, such as former Representatives Peter Smith of Vermont and Mickey Edwards of Oklahoma. Some Republican signers, such as Arne Carlson, a former governor of Minnesota, and Christine Todd Whitman, a former governor of New Jersey, supported Mrs. Clinton for president.
But the letter suggests that Mr. Trump is beginning to face calls from a broadening universe of people to take more aggressive steps to eliminate potential conflicts, such as selling off his real estate holdings and businesses before taking office.
"The only way to solve the problems you face remains divesting into a blind trust managed by an independent trustee or the equivalent," the letter says. "As long as you continue to maintain ownership of the Trump Organization, no other steps that you take will prevent the serious conflicts of interest."
The letter was organized by two former White House ethics lawyers - Richard W. Painter, who served under George W. Bush, and Norman Eisen, who served in the Obama administration - as well as Fred Wertheimer, the founder of an ethics in government group called Democracy 21.
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PHOTOS: Hillary Clinton with her husband, Bill, at President Obama's inauguration in 2013. (PHOTOGRAPH BY CHANG W. LEE/THE NEW YORK TIMES); Omarosa Manigault at Trump Tower on Monday. (PHOTOGRAPH BY HILARY SWIFT FOR THE NEW YORK TIMES)
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April 3, 2012 Tuesday
The President Fumbles the Court Issue
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 626 words
HIGHLIGHT: President Obama needs to make a strong argument in defense of the Affordable Care Act if he wants to be re-elected. His remarks yesterday were a bad start.
I'm sure President Obama knows how important the Supreme Court's decision on health care will be to his re-election, not to mention the future of the country. And I'm equally sure he knows that the issue of Supreme Court appointments should figure highly in his campaign. If he loses, the nation faces what could be the most right-wing court in history, driven by a highly politicized agenda.
But Mr. Obama's maladroit handling of the issue yesterday left me wondering if he is going to be able to make that case effectively in the fall.
Mr. Obama was asked at a news conference about his health insurance reform law. He defended the constitutionality of the individual mandate that is at the core of the reform. He's right about that, and it's perfectly appropriate for him to defend the law.
But instead of offering a considered argument about the mandate's constitutionality and the court's jurisdiction in this case, he fumbled and stumbled into the ideological swamp usually occupied by Republicans when it comes to the court.
"I'd just remind conservative commentators that for years what we've heard is, the biggest problem on the bench was judicial activism or a lack of judicial restraint, that an unelected group of people would somehow overturn a duly constituted and passed law," he said. "Well this is a good example and I'm pretty confident that this court will recognize that and not take that step."
The reaction from the right was ridiculous. Conservative websites ran headlines saying that the president had made an outrageous attack on "unelected" judges. Senator Orrin Hatch, the Republican from Utah, called it a "fantasy" to think "every law you like is constitutional and every Supreme Court decision you don't is 'activist."
That is precisely the Republican yardstick for judging court decisions. The right consistently attacks the court with the argument that federal judges are unelected. Of course they are. That was exactly what the framers had in mind when they wrote the constitutional directive that federal judges be nominated by the president and confirmed by the Senate, shielding them from the whims and pressures of political campaigns. It's an especially important protection these days, when large moneyed interests are free to buy any election they want.
Judges, in the nation's system of separated powers, are assigned a distinct role, and it is not to be politicians in black robes. The protection of Americans' rights depends on having independent and fair-minded judges willing to strike down laws that trample on the Bill of Rights or otherwise overstep the constitutional powers of the executive branch-even when it may not be the popular thing to do. What courts should not do is second-guess legislative judgments that are well-within Congress's proper authority, based on ideological or policy differences. That is precisely the worry in the pending case of the Affordable Care Act.
But Mr. Obama did not say that. He reduced the issue to a quick-and-easy sound bite and left himself open for the Republican attack with his ill-considered comments. In the case of the individual mandate, the issue is whether this court will sweep aside deeply established judicial precedent and cripple the government's ability to enforce the constitution's commerce clause. The mandate is clearly within that established legal framework. It's also troubling that some justices are more focused on whether they like this law than whether this law is constitutional.
That is the argument Mr. Obama needs to make. His comments yesterday were a bad start.
The Right to Strip
Opinion Report: America's No. 1 Foe
Reducing Nuclear Arms Is Not 'Alarming.' It's Necessary.
Opinion Report: Supreme Health
'If I Had a Son He'd Look Like Trayvon'
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October 15, 2016 Saturday
Late Edition - Final
Beneficiaries Reflect Health Law's Strengths and Faults
BYLINE: By ABBY GOODNOUGH and REED ABELSON
SECTION: Section A; Column 0; National Desk; Pg. 10
LENGTH: 1466 words
WASHINGTON -- Cara Suzannah Latil is living proof that the Affordable Care Act works -- but also of why a central piece of the law is in turmoil.
Ms. Latil, 49, who works at a homeless shelter in Santa Fe, N.M., is one of millions of Americans who once found it difficult or impossible to get health insurance because they already had serious illnesses. Hepatitis C was ravaging her liver when she learned in 2014 that she also had breast cancer. Through the health care law, she was able to buy subsidized insurance that paid for all but $800 of her cancer surgery and radiation, she said, as well as tens of thousands of dollars' worth of medications that cured her hepatitis.
But stories like Ms. Latil's help explain a critical challenge for the health law: The subsidies it provides to help people pay for coverage, and the penalties for those who remain uninsured, have not coaxed enough young, healthy people into the insurance marketplaces it created. So the pool of customers in some parts of the country is too sick and too small.
Most Americans get their health insurance through their employers, or via Medicare or Medicaid. But millions who lack those options use the insurance markets set up under the law.
It has turned out that so many marketplace customers need expensive medical care that some insurers are spending more on claims than they earn in premiums. And the federal government's strategies for protecting insurance companies from large losses have not been as effective as hoped.
Insurers, including a few big ones like Aetna and Humana, are withdrawing from the marketplaces in many states, saying they are losing too much money.
Others are sharply raising prices for next year, and the turbulence is fueling Republican criticism -- including from Donald J. Trump during Sunday's presidential debate, in which he called the rate increases ''astronomical.''
A few customers can generate big costs.
Even a small number of customers with serious conditions can greatly increase costs. Roy Vaughn, a senior vice president at BlueCross BlueShield of Tennessee, said that just 5 percent of the company's marketplace customers had accounted for nearly 75 percent of its claims costs.
The company recently announced that it would stop selling marketplace plans in Knoxville, Memphis and Nashville.
There are other reasons insurers are raising their rates or leaving the marketplaces. A big one is that the Obama administration, thwarted by Republican opponents in Congress, has paid out only a fraction of the $2.5 billion it owes insurers under a provision of the health law that was supposed to protect them against unexpectedly large losses during their first few years in the marketplaces.
But these payments would not be so important if more of the roughly 10 million marketplace customers were in good health. The Blue Cross Blue Shield Association reported in March that new customers who bought marketplace plans from its member insurers in 2014 and 2015 had higher rates of hypertension, diabetes, coronary artery disease, depression, H.I.V. and hepatitis C.
Chronically ill patients are worried about next year.
Many of these customers are in better shape after a few years with health insurance. But they are scared about the Affordable Care Act's future.
Marque Dailey of Dallas, who has multiple sclerosis, said his marketplace plan from BlueCross BlueShield of Texas had paid for visits to a neurologist, physical therapy and a drug called Lemtrada that is administered through two series of infusions a year apart. The list price for the treatment is $158,000, although insurers usually negotiate lower rates.
When Mr. Dailey, now 32, was uninsured, he could not treat his symptoms and had to rely more and more on a wheelchair. The stiffness in his legs got so bad, he said, that he had to quit his part-time job as a merchandiser at Coca-Cola, which did not offer insurance. Now he is working again, as a field organizer for a Democratic state legislative candidate. But Blue Cross narrowed the network of doctors and hospitals he could use this year, and he is worried that 2017 will bring even fewer choices.
''I understand I'm an insurance loss,'' Mr. Dailey said. ''I do feel bad about it. But without this, I'm just kind of left out of everything.''
Costs are burdensome to customers, too.
Other marketplace customers with expensive medical needs pointed out that the costs had been a burden to them as well as their insurers, most of which remain profitable even as they lose money in the Affordable Care Act markets.
Vickie Wilkerson, 46, of Shreveport, La., has a plan from Blue Cross and Blue Shield of Louisiana that she said had paid about $21,000 so far this year for injections of Stelara, a drug that has helped her severe psoriasis. She pays just $5 per shot, but only because by the time her doctor prescribed it this year, she had already met the $6,000 deductible on her plan. Two emergency room visits, for bronchitis and a bad fall, had left her with thousands of dollars in bills.
She chose a high-deductible plan, she said, because the subsidy she received covered the monthly premiums in full. She had not anticipated needing emergency care or being put on such an expensive drug. Nor had she realized that by choosing a different type of plan with higher premiums, she could have qualified for extra federal aid that would have helped pay her deductible.
Ms. Wilkerson, who never had insurance through her longtime job as a housekeeper, relied on sporadic charity care until getting marketplace coverage in 2014.
Her worst fear, she said, is that insurance companies ''will find some kind of loophole'' to deny coverage to people with existing conditions, as they did before the health law was passed.
''I don't know what I'd do,'' she said.
Her insurer is raising rates an average of 24 percent next year. But Ms. Wilkerson is looking into whether she qualifies for Medicaid now that Louisiana has expanded it under the Affordable Care Act.
''I'm finally on a medication that is working,'' she said. ''I don't want to have to stop that now and go back to the drawing board.''
Insurers are limiting choices.
Cathy Richardson of Elizabethtown, Pa., who works at her husband's small financial planning business, was a healthy, low-cost customer for the first two years she had coverage through the Affordable Care Act. But early this year, Ms. Richardson, 54, received a diagnosis of Stage 3 rectal cancer and quickly became expensive to her insurer, Capital BlueCross. She has had two operations, chemotherapy, radiation and two additional hospitalizations.
There are signs that Ms. Richardson's insurer is working to contain the costs of sick customers like her: It will not pay for treatment at the larger, more prestigious hospital in her area, requiring her to go to a smaller hospital instead. And a case manager from the insurance company calls her weekly to make sure she is getting the care she needs, which could prevent expensive complications.
The smaller hospital does not have a cancer center, so her oncologist, radiologist and surgeon do not work as a team. ''You have to navigate between the three of them,'' she said, ''and you never know who to go to.''
Still, her costs have been limited to about $5,200. She is bracing for a letter from her insurer, due this month, that will notify her of any price increase and changes to her coverage for 2017.
''Our choices are probably going to be pretty limited,'' she said.
Insurers are frustrated by customers dropping coverage.
The Obama administration is planning greater outreach, through advertising, social media, mailings and email, to new ways to persuade young, healthy Americans to buy marketplace coverage during the next enrollment period, which starts on Nov. 1. It is also taking other steps to address problems with the risk pool, which it says shows signs of improvement.
But insurers say they also wish the government could make it harder for people to drop their coverage after their health problem is treated. Health Care Service Corporation, which operates Blue Cross plans in five states, said less than half of its marketplace customers paid for coverage for the full year.
Ms. Latil dropped her coverage recently; she had finished her hepatitis treatment, a nearly six-month regimen of the drugs Sovaldi, Daklinza and ribavirin. It was not a willful swipe at the system, she said; she was struggling to make her premium payments of $179 a month.
''I got my stuff taken care of,'' said Ms. Latil, who will soon have insurance through her job. ''I am so extremely grateful.''
Follow Abby Goodnough @abbygoodnough and Reed Abelson @ReedAbelson on Twitter.
For more breaking news and in-depth reporting, follow @NYTNational.
URL: http://www.nytimes.com/2016/10/15/us/health-care-insurance-exchange-obamacare.html
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GRAPHIC: PHOTOS: The stories of, from left, Marque Dailey, Vickie Wilkerson and Cara Suzannah Latil help explain the Affordable Care Act's critical flaws.(PHOTOGRAPHS BY COOPER NEILL FOR THE NEW YORK TIMES
MARK OVASKA FOR THE NEW YORK TIMES.) (A11)
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February 4, 2014 Tuesday
Times Minute | Army Recruitment Scam
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HIGHLIGHT: Also on the Minute, a territorial dispute in the South China Sea and the effect of the Affordable Care Act on the full-time work force.
In the Video
Philippine Leader Urges International Help in Resisting China's Sea Claims
Wide-Reaching Army Recruiting Fraud Described by Investigators
Health Care Law May Result in 2 Million Fewer Full-Time Workers
Times Minute | Displaced in South Sudan
Times Minute | A Pair of Rescues
Times Minute | Milestone for Obamacare
Times Minute | Easing a Health Law Rule
Times Minute | New Poll on Health Care
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The New York Times
January 7, 2014 Tuesday
Late Edition - Final
Another Modest Rise for Health Costs
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 10
LENGTH: 834 words
WASHINGTON -- National health spending grew slowly for the fourth consecutive year, increasing 3.7 percent in 2012 to $2.8 trillion, the federal government said Monday. But officials disagreed over whether the Affordable Care Act or lingering effects of the recession were primarily responsible for the remarkable trend.
As a share of the economy, health spending declined slightly, to 17.2 percent in 2012, from 17.3 percent in the prior year. For decades, health spending has grown faster than the economy, taking a bigger bite out of workers' wages and the federal budget.
Health spending averaged about $8,900 a person in 2012, according to the annual report issued Monday by the government.
The authors of the report -- civil servants at the Centers for Medicare and Medicaid Services -- said that the Affordable Care Act, adopted in March 2010, had only ''a minimal impact on overall national health spending growth through 2012'' and had not yet significantly reined in or accelerated its growth.
''The relatively low rates of growth that we've seen over the last four years are consistent with the historical trends that we've seen when we look at health spending and gross domestic product,'' said Aaron C. Catlin, an economist and co-author of the report. ''It's consistent with what we've seen in post-recessionary periods in the past.''
But the White House said the data vindicated President Obama's health care policies.
''The years 2009 to 2012 saw the slowest growth in U.S. health care expenditures since the government started collecting this information in the 1960s,'' said Jeanne M. Lambrew, a health policy coordinator at the White House.
''While there is a debate about how much the Affordable Care Act has contributed to this health cost slowdown,'' Ms. Lambrew said, ''there is no doubt that it reduced Medicare spending growth, and most experts believe that Medicare savings spill over into the private sector.''
Some experts, including the Congressional Budget Office, have reduced their projections of federal health spending, based in part on their belief that pervasive changes in the health care system would endure.
However, the authors of the new report, published in the journal Health Affairs, were more cautious.
''From our perspective,'' they wrote, ''more historical evidence is needed before concluding that we have observed a structural break in the historical relationship between the health sector and the overall economy.''
The last recession, the worst in decades, ran from December 2007 to June 2009. Mr. Catlin said that delayed effects of the recession -- curtailed growth of the economy, employment and personal income -- appeared to be the main reason for relatively low growth of health spending in recent years.
Some provisions of the new health care law increased spending and others reduced it, but the overall effects on spending were modest, said Anne B. Martin, an economist who was the principal author of the report. She estimated that the law had increased national health spending by a cumulative total of one-tenth of 1 percent from 2010 through 2012.
Comparing the experience of recent years, the report said that spending on hospitals and doctors increased at a faster rate in 2012 than 2011, while spending on prescription drugs and nursing homes grew more slowly.
Spending on hospital care increased 4.9 percent in 2012, to $882 billion, mainly because of a rise in prices and in the intensity and complexity of services, the report said. By contrast, the increase in 2011 was 3.5 percent.
At the same time, the report said, spending for doctors' services and outpatient clinics grew by 4.6 percent in 2012, to $565 billion -- up from growth of 4.1 percent in 2011.
But, it said, spending for prescription drugs grew just four-tenths of 1 percent in 2012, to $263 billion, compared with an increase of 2.5 percent in 2011.
''This reduced growth rate was driven largely by a slowdown in overall prices paid for retail prescription drugs as numerous brand-name blockbuster drugs -- most notably Lipitor, Plavix and Singulair -- lost patent protection in late 2011 and in 2012 and as generic versions became available,'' the report said.
Almost three-fourths of all prescriptions filled in 2012 cost $10 or less per prescription, the study said. Generic drugs accounted for 77 percent of all prescriptions filled in 2012, up from about 70 percent in 2011, it said.
The aging of the baby boom generation is reflected in the new data. Enrollment in Medicare increased 4 percent in 2012, the largest one-year increase in 39 years, the report said. More than half of the new beneficiaries joined Medicare Advantage plans managed by private insurers under contract with the government. More than one-fourth of the 50 million Medicare beneficiaries are now in such private plans.
Spending on Medicare increased 4.8 percent, to $573 billion in 2012, while federal and state spending on Medicaid, for low-income people, grew 3.3 percent, to $421 billion, the report said.
URL: http://www.nytimes.com/2014/01/07/health/health-spending-rises-slowly-for-fourth-year-in-a-row.html
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GRAPHIC: CHART: Slow Growth in Health Spending: Experts at the Centers for Medicare and Medicaid Services said in a report that national spending on health care continued to be modest in 2012. (Sources: Centers for Medicare and Medicaid Services
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October 21, 2015 Wednesday
Late Edition - Final
Insurance Out of Reach for Many, Despite Law
BYLINE: By STACY COWLEY
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1
LENGTH: 1390 words
JACKSONVILLE, N.C. -- When Billy Sewell began offering health insurance this year to 600 service workers at the Golden Corral restaurants that he owns, he wondered nervously how many would buy it. Adding hundreds of employees to his plan would cost him more than $1 million -- a hit he wasn't sure his low-margin business could afford.
His actual costs, though, turned out to be far smaller than he had feared. So far, only two people have signed up.
''We offered, and they didn't take it,'' he said.
Evidence is growing that his experience is not unusual. The Affordable Care Act's employer mandate, which requires employers with more than 50 full-time workers to offer most of their employees insurance or face financial penalties, was one of the law's most controversial provisions. Business owners and industry groups fiercely protested the change, and some companies cut workers' hours to reduce the number of employees who would be eligible.
But 10 months after the first phase of the mandate took effect, covering companies with 100 or more workers, many business owners say they are finding very few employees willing to buy the health insurance that they are now compelled to offer. The trend is especially pronounced among smaller and midsize businesses in fields filled with low-wage hourly workers, like restaurants, retailing and hospitality. (Companies with 50 to 99 workers are not required to comply with the mandate until next year.)
''Based on what we've seen in the marketplace, we're advising some of our clients to expect single-digit take rates,'' said Michael A. Bodack, an insurance broker in Harrison, N.Y. ''One to 2 percent isn't unusual.''
Nationwide, the Affordable Care Act has significantly reduced the number of Americans without health insurance. Around 10.7 percent of the country's under-65 population was uninsured in the first three months of this year, down from 17.5 percent five years earlier, according to the National Health Interview Survey, a long-running federal study. Some 14 million previously uninsured adults have gained coverage in the last two years, the Obama administration estimates.
Most of those gains, though, have come from a vast expansion of Medicaid and from the subsidies that help lower-income people buy insurance through federal and state exchanges. Workers who are offered affordable individual coverage through their employers -- a group that the employer mandate was intended to expand -- are not eligible for government-subsidized insurance through the exchanges, even if their income would otherwise have qualified them.
But for those trying to get by on near-minimum wages, a plan that qualifies as ''affordable'' can still seem far out of reach.
That is the case for many of Mr. Sewell's workers. He employs 1,800 people at the 26 Golden Corral franchises he owns in six Southern and Midwestern states, and previously offered insurance only to his salaried management staff. In January, when the employer mandate took effect, he made the same insurance plan, with a bigger employer contribution, available to all employees working an average of 30 or more hours a week.
Running the math on his plan -- a typical one for the restaurant industry -- illustrates why a number of low-wage workers are falling through gaps in the Affordable Care Act.
The annual premium for individual coverage through the Golden Corral Blue Cross Blue Shield plan is $4,800. Mr. Sewell pays 65 percent for service workers, leaving them with a monthly cost of $140.
The health care law defines affordable employer-sponsored insurance as that priced at 9.5 percent or less of an employee's annual household income for individual coverage. (Because employers do not know how much money their workers' relatives make, there are several ''safe harbors'' they can use for compliance, including basing their calculation on only their own employees' wages.) Mr. Sewell's insurance meets the test, but $65 per biweekly paycheck is more than most of his workers are willing -- or able -- to pay for insurance that still carries steep out-of-pocket costs, including a $2,500 deductible.
Clarissa Morris, 47, has been a server at the Golden Corral here for five years, earning $2.13 an hour plus tips. On a typical day, she leaves the restaurant with about $70 in tips. Her husband makes $9 an hour at Walmart but has been offered only a part-time schedule there, without benefits. Their combined paychecks barely cover their rent and daily essentials.
''It's either buy insurance or put food in the house,'' she said. On the rare occasions that she gets sick, she visits a local clinic with sliding-scale fees. It costs her $25 for a visit, and $4 to fill prescriptions at Walmart.
Brad Mete, the managing partner of Affinity Resources, a staffing agency in Dania Beach, Fla., began offering insurance this year to most of his workers only because the law required it. He said the alternative, paying a penalty of about $2,000 per full-time employee, was unthinkable, ''That would put us out of business, in one swoop.''
Trying to persuade his hourly workers to buy the insurance is ''like pulling teeth,'' he said. His company's plan costs $120 a month, but workers making about $300 a week are reluctant to spend $30 of it on insurance.
The employer mandate has not yet had any noticeable effect on the number of workers enrolled in employer-sponsored health plans, according to a survey by Mercer, a human resources consulting firm. Most of the newly eligible appear to be obtaining coverage elsewhere, such as through the plan of a parent or spouse, or are continuing to go without, said Tracy Watts, a Mercer consultant.
A study by ADP, the payroll processing giant, found an income tipping point at which most employees who are eligible for health insurance will buy it: $45,000 a year.
Workers making $15,000 to $20,000 a year buy employer-sponsored individual insurance when it is offered only 37 percent of the time. That rate rises at every income increment ADP studied until $45,000, when it reaches 82 percent and levels off. Further income gains have virtually no effect on the rate, ADP found.
The study was conducted in 2013, before many of the Affordable Care Act's provisions took effect, but ADP's recent figures do not indicate significant changes in that pattern, according to Christopher Ryan, an ADP research executive.
Low participation can pose problems for employers, especially smaller ones. Insurers are reluctant to sell policies to companies with low enrollment, because they fear that only the sickest employees will buy coverage.
Until this year, most insurers would not cover groups that fell short of their minimum participation requirements. The Affordable Care Act struck down that policy -- a sea change for the industry -- by prohibiting minimum participation rules from being used to deny coverage to any employer with 100 or more workers. But there is a big loophole: Insurers are required to issue the policies, but they are not required to renew them.
Mario K. Castillo, a lawyer in Houston who has extensively studied the new law, said it was poorly understood in the industry, and a bureaucratic nightmare.
''They have to issue you a policy, but dropping it after one year is perfectly legal,'' he said. ''If you're in this space, you essentially have to shop for insurance every year.''
For employees, forgoing coverage can mean facing tax penalties. Ms. Morris said she was surprised by the $95 fee she had to pay this year for being uninsured in 2014. ''I had kind of heard about it, but I didn't think it was going to kick in until later,'' she said.
Around 7.5 million taxpayers paid the fine, according to a preliminary report by the Internal Revenue Service. That is significantly more than the three million to six million the government had forecast.
Low-income, full-time workers like Ms. Morris may prove to be some of the hardest people to bring into the ranks of the insured, said Gary Claxton, a vice president at the Kaiser Family Foundation, which conducts an annual study on employer health benefits.
''This is one of the outcomes of trying to keep employer-based coverage in place,'' Mr. Claxton said. ''These are folks that didn't have coverage before, and they're not being given much help to get coverage now.''
URL: http://www.nytimes.com/2015/10/20/business/many-low-income-workers-say-no-to-health-insurance.html
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GRAPHIC: PHOTOS: Billy Sewell said only two of his 600 workers at Golden Corral signed up for insurance. Clarissa Morris says she cannot afford it. (PHOTOGRAPHS BY LOGAN R. CYRUS FOR THE NEW YORK TIMES) (B7)
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(In Practice)
November 14, 2013 Thursday
California Shuts Down Sites Mimicking State Insurance Marketplace
BYLINE: Ian Lovett
SECTION: US
LENGTH: 393 words
HIGHLIGHT: The California attorney general’s office has shut down ten websites that mimicked state’s official health insurance marketplace.
LOS ANGELES-The California attorney general's office has shut down ten websites that mimicked state's official health insurance marketplace, the attorney general, Kamala Harris, announced Wednesday.
"These websites fraudulently imitated Covered California in order to lure consumers away from plans that provide the benefits of the Affordable Care Act," Ms. Harris said in a prepared statement. "My office will continue to investigate and shut down these kinds of sites."
While not without its own hiccups, the rollout of the Affordable Care Act has been smoother in California than in many other parts of the country. Covered California, the state's insurance exchange, enrolled more people in private healthcare plans during the first month of open enrollment than any other state health exchange or the beleaguered federal marketplace, which serves 36 states.
Ms. Harris's announcement on Wednesday was the latest example of state officials in California, where Democrats hold all statewide offices, enthusiastically pushing Californians to buy healthcare plans on the state's exchange.
"I urge Californians to avoid healthcare scams by visitingcoveredca.com," Ms. Harris said.
The attorney general's office began investigating websites that imitated Covered California in September.
The sites all used domain names similar to coveredca.com, including coveredcalifornia.com and californiabenefitexchange.com, and they used phrases like "Get Covered" and "Covered California" to attract consumers, according to the attorney general's office. However, the sites were operated by private health insurance brokers not affiliated with the state's official exchange.
The California Affordable Care Act prohibits entities from claiming to provide services on behalf of Covered California without a valid agreement with the state exchange. Multiple website operators were sent cease and desist orders, demanding they either shut the sites down, or redirect traffic to the official Covered California website, and ten operators have now been shut down, according to the attorney general's office.
In urging residents to visit the state exchange, Ms. Harris warned that health insurance plans sold outside the official exchange before Jan. 1, 2014, would not qualify for federal subsidies, and would not have the consumer protections guaranteed under the Affordable Care Act.
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(You're the Boss)
July 10, 2012 Tuesday
Having Lost the Health Care Battle, the N.F.I.B. Readies for a Long War
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1036 words
HIGHLIGHT: Acknowledging that full repeal is a long shot, the group seems to have settled on a less ambitious course of stripping the law of the elements it considers most odious.
Now that the Supreme Court has largely upheld the Affordable Care Act, what is the next move for the lead plaintiff in the suit to repeal the law? This, of course, is the National Federation of Independent Business, the small-business trade association, and while the N.F.I.B. might have found much to like in the Affordable Care Act - the whole notion of insurance exchanges where small companies could compare and then buy insurance coverage for their employees was taken directly from a bill that the federation helped write - it in fact found much more to dislike. Nothing is likely to happen before the election this November, said the federation's chief executive, Dan Danner, but the group is already preparing its Plan B - and Plan C.
The group's preferred outcome, full repeal of the health care law, does not require a change in election strategy, because the federation was likely to be supporting Republicans hostile to the health law anyway. But Mr. Danner acknowledged that full repeal was a long shot, and he seemed to have settled on a less ambitious course of stripping the law of what the N.F.I.B views as its most odious elements. "I think there's growing sensitivity on both sides of the aisle to some of the things in the legislation that without total repeal could be changed," Mr. Danner said.
To that end, he said, the group planned to spend the next four months pressuring candidates for Congress - Democrats and Republicans alike. For example, referring to the individual mandate, Mr. Danner rehearsed a question the group planned to pose to a Democratic senator in a very tight race for re-election: "Claire McCaskill, you're running for the Senate in Missouri, now that it's clear that we're talking about a tax, are you O.K. with that, this enormous new tax on largely the middle class and young people?" Mr. Danner said his group planned to question "pretty much everybody that's running." (Ms. McCaskill's office did not respond to a request for an answer to the N.F.I.B.'s question.)
Mr. Danner said the mandate would affect the federation's self-employed members - about 16 percent of the group's membership, according to Kevin Kuhlman, a manager for legislative affairs at the federation. Mr. Kuhlman added that the mandate would force other small business owners who could not afford insurance to buy it. "It diverts potential investment in a business to a product," he said. However, the nonpartisan Congressional Budget Office and Congress's Joint Committee on Taxation have estimated that in 2016 only four million people will have to pay the government for refusing to buy insurance, and many of these people would be upper-income.
Apart from seeing the individual mandate removed, the organization would like to repeal an annual fee on health insurers that Senate Democrats drafted to help pay for the overhaul. The provision, which the N.F.I.B. describes as a tax, will raise at least $87.4 billion from 2014 to 2020. "The tax will primarily be on health care plans in the small group market, where our guys are," he said, "so we're pretty confident that that $87 billion gets passed directly down to the small businesses purchasing health care." The Congressional Budget Office has also said that insurers will pass the cost of the fee to customers in premiums. Large companies typically self-insure, and self-insurance is excluded from the fee. (On the other hand, Jason Furman, an economic adviser to the Obama administration, points out that the C.B.O. has also predicted that exchanges paid for in part by the fee should actually make health insurance cheaper for small businesses by reducing administrative costs and increasing competition among insurers.)
And the group plans to push other changes. "We'd still like to see expanded, not diminished, use of health savings accounts and flexible spending accounts, because they're largely taken off the table in the law," Mr. Danner said. And "something that hasn't been addressed in the law, and we'd like to sure see added, because it goes directly to costs, is medical malpractice reform."
At the same time, employees at the Health and Human Services Department who are defining the health care law's essential benefits packages will continue to hear from federation lobbyists. The law requires the Health and Human Services Department to stipulate the minimum benefits for all plans in the individual and small group markets, and Mr. Danner said the federation is worried about additional coverage requirements that could drive up costs for employers. "It makes a great deal of difference if that's all the bells and whistles," said Mr. Danner. "The companies don't get to decide, unfortunately, what they provide. H.H.S. will decide that."
And the federation will be active in every state capital, too, because state governments are charged with setting up the law's insurance exchanges, one for individuals and one for small businesses. "Clearly in a lot of the states, things were somewhat on hold pending this decision, and now things probably move more quickly," Mr. Danner said. "We have a great deal of concern about how the exchanges are going to be set up, and if in fact they're going to offer lots of choices and lower costs for small business."
However, several Republican governors have said that they would at least wait until after the election to make a decision on whether to set up exchanges - where states do not create an exchange, the federal government was slated to do it for them - Mr. Kuhlman said later that the organization was not taking a stand on when, or whether, a state should begin work on its exchanges.
Mr. Danner said his organization hadn't t figured out what precisely it wanted in the exchanges. "We don't have a blueprint of how you should set up every state exchange," he continued. "But I think what we do want is a seat at the table as these are being set up in all the states, and we'll push pretty hard to have that."
How the Health Care Law Affects Your Business
Business Owners Try to Make Sense of Health Care
Is Dividing a Company the Way to Beat the Affordable Care Act?
Doing the Math on Employer Health Insurance
Debating Whether Businesses Will Continue to Offer Health Insurance
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November 2, 2016 Wednesday
Late Edition - Final
How Health Care Hurts Your Paycheck
BYLINE: By REGINA E. HERZLINGER, BARAK D. RICHMAN and RICHARD J. BOXER.
Regina E. Herzlinger is a professor of business administration at Harvard University. Barak D. Richman is a professor of law and business administration at Duke University. Richard J. Boxer is a professor at the David Geffen School of Medicine at U.C.L.A.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTORS; Pg. 25
LENGTH: 921 words
If there is a coherent theme to this year's election, it is the growing economic frustration of working Americans. While trade has been the chief scapegoat, a major culprit has received much less attention: the rising cost of health insurance.
Recent news of large price increases for plans on the Affordable Care Act's insurance exchanges was the latest example of an unsustainable trend. But those exchanges sell insurance to only about 12 million individuals. Most people with private health insurance, about 150 million individuals, receive coverage through employers. And for those people, prices have been rising for years.
A Kaiser Foundation report released in September explained that since 1999, health care premiums for employer-sponsored insurance programs have risen more than three times faster than wages. Today's workers are paying an average of $18,000 for health insurance that covers fewer services each year, as employers shift costs to their employees through higher deductibles, co-payments and shares of premiums.
Unlike the plans purchased on insurance exchanges, where individuals pay directly for their policies, employers pay for most private health insurance on their employees' behalf. Economics research suggests that for each dollar an employer spends on an employee's health insurance premium, roughly one dollar is removed from that person's take-home pay. But these costs remain hidden. Workers know their take-home pay has stagnated, but they may not attribute that stagnation to health care costs.
Workers have little control over this enormous expense made on their behalf. Most have few, if any, health insurance options and cannot trade dollars spent on insurance for higher take-home pay. They cannot shop around for or economize on what is probably their most expensive annual purchase. In turn, insurers are not pressured to offer more affordable insurance products.
A minor tweak to our tax code could go a long way to bring more choice, affordability and personal control to how workers purchase health insurance. Current law allows individuals to avoid taxes on money spent on insurance premiums only if their employers purchase insurance on their behalf. What if employers transferred to their employees the amount they now spend on coverage and the law allowed employees to deduct that spending from their taxes?
And what if those laws allowed employees to opt not to spend that entire sum on health insurance, but instead take some home as wages? If an employee in a marginal tax bracket of 25 percent were given an $18,000 budget to purchase insurance, but opted for a plan that costs only $14,000, she could take an additional $3,000, post-tax, home to her family.
This slight change would turn the economic tables for the millions of Americans who get health insurance through their employers. Abundant research has shown that low- and middle-income workers have a strong preference for low-cost plans, much more than what their employers currently offer. If workers know they can increase take-home wages by purchasing less expensive insurance, they will demand more insurance options, and insurers are likely to respond. To avoid the chance that cash-strapped families purchase inadequate plans, insurance plans would have to meet the Affordable Care Act's minimum standards. The law's requirement to purchase insurance, with penalties for non-purchase, would lessen the possibility that workers would keep all the money rather than buy insurance.
Freeing workers' choices for insurance would also bring pressures on insurers to create new products that control costs, such as bundling of homeowners, auto and health insurances, or enabling people between 55 and 64 years old to access Medicare. State legislatures would feel similar pressures to adjust regulations to support competitive insurance marketplaces.
Stiffer competition and cost pressures on insurers, in turn, would force providers to offer more efficient care, such as by replacing outpatient and emergency room visits with telemedicine technology.
Our proposal charts a bipartisan path, bolstering the Democratic mandate for universal care working within the Affordable Care Act, while heeding the Republican call for competition and choice. It also presses further than the main presidential candidates. Hillary Clinton proposes reducing the cost of pharmaceuticals, eliminating taxes on high-end policies, improving cost transparency and allowing people over 55 to buy into Medicare. Donald J. Trump, who wants to repeal the Affordable Care Act, calls for creating tax-free health savings accounts and facilitating cross-state competition. Both recommend assorted tax credits. Each of these approaches aims to soften the effects of rising prices. But neither empowers workers to invigorate the marketplace and make prices more competitive.
America has prospered because it has harnessed the power of competitive markets to enable growth, and it is not hyperbole to say that middle-class disaffection threatens the very compact that generated this prosperity. Competitive markets do not merely force companies to act efficiently and produce valuable offerings. In assuring Americans that they can control their budgets and have a voice in their life decisions, they also serve as a reliable counterforce to the economic discontent that has roiled this election season.
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URL: http://www.nytimes.com/2016/11/02/opinion/how-health-care-hurts-your-paycheck.html
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(You're the Boss)
July 17, 2014 Thursday
Are More Companies Offering Health Insurance? For an Answer, Look to Massachusetts
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 927 words
HIGHLIGHT: After the Massachusetts health insurance overhaul, there was an increase in the percentage of businesses offering their employees coverage.
For years, The Agenda has reported dueling predictions from economists and other pundits about whether businesses, especially small businesses, will stop offering health insurance rather than comply with the requirements of the Affordable Care Act. For an example, see Ezekiel J. Emanuel's claim that by 2020, more than 80 percent of private-sector workers will buy their own insurance.
The early evidence, however, suggests the opposite trend. An April study by the non-profit Rand Corporation found that in the six months between September 2013 and March 2014, the number of people who received health insurance through an employer grew from 109 million to nearly 117 million, an increase of about 8 percent. (The number of people who got new insurance from an employer was actually larger than that, but it was offset by the people who lost their company insurance, many of whom replaced that insurance with an individual policy or Medicaid.)
A second, so far unpublished, study by the Urban Institute found a similar but smaller result - the growth in employer provided coverage was about half what Rand reported, according to Genevieve M. Kenney, a health economist with the Institute.
These studies, which rely on much smaller sample sizes than more authoritative government surveys, leave several questions unanswered. Chief among them is whether the increase reflects more workers accepting existing offers of insurance or more companies choosing to offer insurance. Nor is it clear whether the increase is occurring at small businesses, big businesses or both.
According to the latest data from the Census Bureau, businesses with 500 or more workers employ 51 percent of the workforce, while those with fewer than 500 workers have 49 percent. (Those with fewer than 100 workers employ 35 percent.)
To gauge what might be happening now, we can turn to the experience in Massachusetts, where a 2006 health care overhaul served as the model for the Affordable Care Act. And the Massachusetts experience is striking. There, too, in the first year after the overhaul took effect, the number of people insured through an employer grew - not by as much as the RAND and Urban Institute data project, but Massachusetts employers already covered a higher share of the state's residents than employers across America do today.
In the Bay State, the increase did not come from more workers deciding to accept existing offers of health insurance. According to data collected by the state, the so-called take-up rate in 2007 was the same as in 2005, 78 percent. What did change was the number of companies offering insurance. In 2005, 60 percent of the smallest companies - those with between two and nine employees - offered insurance; in 2007, that share shot up to 67 percent, a 12 percent increase. Interestingly, the effect was delayed among companies with between 10 and 50 employees. In 2007, the offer rate among those companies had not changed much from 2005. By 2009, though, the rate had increased to 92 percent from 88 percent before falling again in 2010. Across all Massachusetts businesses, most of which are small, the share offering health insurance increased about 10 percent from 2005 to 2010.
In a 2011 paper recapping the effects of the Massachusetts overhaul on insurance coverage there, Jonathan Gruber, a health economist who helped design the Affordable Care Act, argued that the pressure the individual mandate placed on people to have insurance forced more employers to offer it. "There is no obvious explanation for this increase in employer offering as the law introduces incentives for employers to drop insurance (by covering their low income employees outside the employer setting) and does little to penalize those firms that do drop coverage," he wrote. "The best potential explanation for this result is that there was a non-market impact of the mandate on employer behavior, with employees demanding coverage to meet the mandate and employers increasing coverage to meet the demand."
What was happening in the rest of the United States at that time? In the early 2000s, Massachusetts companies offered health insurance at a rate similar to the country as a whole. (The national rates for offering insurance have been reported over the years in the Kaiser Family Foundation's annual Employer Health Benefits Survey.) This was in large part driven by the smallest companies, which make up the largest share of all businesses. In those years, the share of very small Massachusetts companies that offered insurance closely tracked the national share, while the state's bigger small businesses (especially those with 10 to 24 employees) were more likely to offer employees insurance.
But in 2005 there was a steep drop-off nationally in the number of small companies offering insurance, even as the number ticked up in Massachusetts. Since then, the offer rate across all companies in the United States has stabilized at about 60 percent, compared to 76 percent in post-overhaul Massachusetts.
We will have a better sense of whether a shift similar to what happened in Massachusetts is occurring now in the whole country when the Kaiser Foundation releases its 2014 employer survey, in September. In the meantime, The Agenda will take a look at how Massachusetts's health care law has affected small businesses in the state, especially those offering coverage to employees for the first time. If you own a Massachusetts business and have a story about the law's impact on your company, please share it. Post a comment below, or send us an email.
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January 16, 2014 Thursday
Late Edition - Final
Federal Judge Upholds Health Care Subsidies
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 753 words
WASHINGTON -- A federal judge rejected a legal challenge on Wednesday to a central part of President Obama's health care law, ruling that millions of low- and moderate-income people could obtain health insurance subsidies regardless of whether they bought coverage through the federal insurance exchange or in marketplaces run by the states.
Critics of the law had said that a literal reading of it would allow subsidies only in the 14 states that ran their own exchanges. But the judge, Paul L. Friedman of the Federal District Court here, said that was absurd and contrary to the whole purpose of the Affordable Care Act.
''The plain text of the statute, the statutory structure and the statutory purpose make clear that Congress intended to make premium tax credits available on both state-run and federally facilitated exchanges,'' Judge Friedman said.
After analyzing the law and its legislative history, he said, ''Congress assumed that tax credits would be available nationwide'' and ''on any exchange, regardless of whether it is operated by a state'' or by federal officials.
The ruling is important because the federal government runs the exchange serving 36 states, which account for about two-thirds of the nation's population.
Ronald F. Pollack, the executive director of Families U.S.A., a liberal-leaning advocacy group, said the ruling was ''an important win for health care consumers across the country.''
Sam Kazman, general counsel of the Competitive Enterprise Institute, a libertarian advocacy group that is coordinating and helping finance the lawsuit, said the plaintiffs would appeal the decision.
From Oct. 1, when the exchanges opened, through Dec. 28, nearly 1.2 million people selected health insurance plans in the federal marketplace, and nearly a million chose plans in state exchanges.
About four-fifths of people choosing health plans at both levels of government qualified for subsidies that reduced their premiums. Subsidies may be available to people with annual incomes up to $45,960 for individuals and up to $94,200 for a family of four.
The lawsuit, Halbig v. Sebelius, was filed by several people in states that use the federal exchange: Tennessee, Texas, Virginia and West Virginia. They objected to being required to buy insurance even with subsidies to help defray the cost.
They said the health care law authorized subsidies specifically for insurance bought on ''an exchange established by the state.'' Congress, they said, provided subsidies in that way as an incentive for states to establish and operate exchanges, rather than leaving the task to the federal government.
However, Judge Friedman found no evidence of such a purpose. He quoted remarks on the Senate floor by Senator Max Baucus, Democrat of Montana and an architect of the law, who said in December 2009 that Congress was giving states a choice to set up their own exchanges or to allow the federal government to do so.
When federal officials create an exchange, Judge Friedman said, they ''stand in the shoes of the state.''
In voting for the Affordable Care Act, Democrats in Congress assumed that states would set up their own exchanges. But many Republican governors and state legislators balked, and opposition to the law became a rallying cry for the party.
Judge Friedman said the plaintiffs' argument seemed intuitively appealing. The section of the law providing health insurance subsidies, ''viewed in isolation, appears to support plaintiffs' interpretation'' because ''the federal government, after all, is not a state,'' he said.
But this reading of the law leads to ''strange or absurd results,'' the judge said, adding that courts must interpret statutes as a whole, not just isolated provisions.
The first page of the law declares the intent of Congress to ensure ''health care for all Americans.''
''Plaintiffs' proposed construction in this case -- that tax credits are available only for those purchasing insurance from state-run exchanges -- runs counter to this central purpose of the Affordable Care Act: to provide affordable health care to virtually all Americans,'' Judge Friedman said.
Thus, he said, the regulation in question, issued by the Internal Revenue Service in May 2012, was a reasonable interpretation of the law and was consistent with the intent of Congress to provide subsidies in the federal exchange as well as state exchanges.
Similar lawsuits, challenging subsidies in the federal exchange, have been filed by several Virginia residents and by state officials in Oklahoma and Indiana.
URL: http://www.nytimes.com/2014/01/16/us/judge-upholds-rights-to-subsidies-in-health-care-law.html
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March 24, 2017 Friday
Late Edition - Final
Trump, Demanding Vote on Imperiled Health Bill, Tells G.O.P.: Now or Never
BYLINE: By JULIE HIRSCHFELD DAVIS, ROBERT PEAR and THOMAS KAPLAN; Jennifer Steinhauer, Emmarie Huetteman and Margot Sanger-Katz contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1832 words
WASHINGTON -- President Trump issued an ultimatum on Thursday to recalcitrant Republicans to fall in line behind a broad health insurance overhaul or see their opportunity to repeal the Affordable Care Act vanish, demanding a Friday vote on a bill that appeared to lack a majority to pass.
The demand, issued by his budget director, Mick Mulvaney, in an evening meeting with House Republicans, came after a marathon day of negotiating at the White House and in the Capitol in which Mr. Trump -- who has boasted of his deal-making prowess -- fell short of selling members of his own party on the health plan.
House Speaker Paul D. Ryan emerged from the session and announced curtly that Mr. Trump would get his wish for a vote on Friday. Mr. Ryan refused to answer reporters' questions about whether he expected the measure to pass.
Although the House Republicans' closed-door meeting became a cheerleading session for the bill, their leaders braced for a showdown on the floor, knowing they were likely to be at least a handful of votes short of a majority for the health insurance bill and would need to muscle their colleagues to the last to prevail.
Some conservatives were still concerned that the bill was too costly and did not do enough to roll back federal health insurance mandates. Moderates and others, meanwhile, were grappling with worries of their states' governors and fretted that the loss of benefits would be too much for their constituents to bear.
Mr. Ryan had earlier postponed the initial House vote that was scheduled for Thursday to coincide with the seventh anniversary of the Affordable Care Act's signing. Mr. Trump confronted the possibility of a humiliating loss on the first significant legislative push of his presidency.
At a White House meeting with members of the hard-line Freedom Caucus earlier on Thursday, Mr. Trump had agreed to the conservatives' demands to strip federal health insurance requirements for basic benefits such as maternity care, emergency services, mental health and wellness visits from the bill. But that was not enough to placate the faction, part of the reason that Thursday's vote was placed on hold.
As House leaders struggled to negotiate with holdouts in the hopes of rescheduling the vote, Mr. Trump sent senior officials to the Capitol with a blunt message: He would agree to no additional changes, and Republicans must either support the bill or resign themselves to leaving President Barack Obama's signature domestic achievement in place.
''We have a great bill, and I think we have a good chance, but it's only politics,'' Mr. Trump said earlier Thursday, as it was becoming clear that his negotiating efforts had failed to persuade enough members of his party to back the plan -- which was years in the making -- to repeal and replace the health law.
Privately, White House officials conceded that competing Republican factions were each demanding changes that could doom the effort, placing the measure in peril and Mr. Trump's chances of succeeding at a high-stakes legislative deal in jeopardy. With some of its demands in place, the Freedom Caucus ratcheted up its requests, insisting on a repeal of all regulatory mandates in the Affordable Care Act, including the prohibition on excluding coverage for pre-existing medical conditions and lifetime coverage caps.
Mr. Trump, who has touted his negotiating skills and invited the label ''the closer'' as the vote approached, was receiving a painful reality check about the difficulty of governing, even with his own party in power on Capitol Hill.
''Guys, we've got one shot here,'' he told members of the Freedom Caucus at a meeting in the Cabinet Room, according to a person present in the room who spoke on the condition of anonymity because the meeting was private. ''This is it -- we're voting now.''
''The choice is yes or no,'' Representative Joe Barton, Republican of Texas and a member of the Freedom Caucus, said on Thursday night. ''I'm not going to vote no to keep Obamacare. That'd be a stupid damn vote.''
Others were unconvinced.
Having secured Mr. Trump's acquiescence to eliminate the requirement that insurers offer ''essential health benefits,'' members of the Freedom Caucus pressed their advantage. While they did not specify precisely which regulations they wanted to eliminate, the section they wanted to gut requires coverage for pre-existing health conditions, allows individuals to remain on their parents' health care plans up to age 26, bars insurers from setting different rates for men and women, prohibits annual or lifetime limits on benefits, and requires insurers to spend at least 80 percent of premium revenue on medical care.
''We're committed to stay here until we get it done,'' said Representative Mark Meadows, Republican of North Carolina and the chairman of the Freedom Caucus. ''So whether the vote is tonight, tomorrow or five days from here, the president will get a victory.''
He said 30 to 40 Republicans planned to vote ''no''; House leaders can afford to lose only 22 in order to pass the bill.
But for every concession Mr. Trump made to appease critics on the right, he lost potential rank-and-file supporters in the middle, including members of the centrist Tuesday Group who had balked at the bill's Medicaid cuts and slashed insurance benefits. Moderate Republicans in that group went to the White House on Thursday but emerged unmoved in their opposition.
''There's a little bit of a balancing act,'' conceded Sean Spicer, the White House press secretary.
Representative Leonard Lance, Republican of New Jersey, said he still opposed the bill because he did not believe it would give people ''complete and affordable access'' to health insurance.
At the same time, a new estimate of the bill's cost and its impact on health coverage further soured the picture for wavering lawmakers. The nonpartisan Congressional Budget Office on Thursday issued a report on the revised version of the health care bill showing that it would cost more than the original version but would not cover more people. The report said the bill, like the original version, would result in 24 million fewer Americans having health insurance in 2026 than under current law.
But recent changes to the bill, made through a series of amendments introduced on Monday, would cut its deficit savings in half. Instead of reducing the deficit by $337 billion, the new version of the bill would save only $150 billion over the decade.
The budget office did not consider the effects of various additional changes that remain under negotiation, including eliminating benefit requirements and other health insurance regulations.
A Quinnipiac University national poll found that voters disapproved of the Republican plan by lopsided margins, with 56 percent opposed, 17 percent supportive and 26 percent undecided. The measure did not even draw support among a majority of Republicans; 41 percent approved, while 24 percent were opposed.
President Trump appealed to supporters to weigh in, assuring them in a video on Twitter, ''Go with our plan. It's going to be terrific.''
You were given many lies with #Obamacare! Go with our plan! Call your Rep & let them know you're behind #AHCA â[#x17e]¡ï¸ https://t.co/xAX4GJiO8z pic.twitter.com/qp90G49e0j -- President Trump (@POTUS) March 23, 2017
The chaotic process that unfolded on Thursday exposed Republicans to criticism that they were moving recklessly in a desperate bid to get their plan passed. Representative Raúl Labrador, Republican of Idaho and a Freedom Caucus member, said the party's leaders had tried to ram through the measure over their members' objections. He panned what he described as a ''brute force'' strategy that resembled the approach of former Speaker John A. Boehner, Republican of Ohio.
''It's better to get it right than to get it fast,'' Mr. Labrador said.
It was not clear that the changes that Mr. Trump has agreed to and those being demanded could survive. Under the strict budget rules being used to advance the bill, changes to the Affordable Care Act must affect federal spending or revenues. Regulatory measures that affect private health policies, not government programs like Medicaid, are highly likely to be challenged by Senate Democrats. If the Senate parliamentarian rules in the Democrats' favor, those changes in the House would be stripped from the bill.
The emerging power of the Freedom Caucus, a group that has been historically marginalized in policy making but a thorn in the side of leadership, is one of the surprises of the rushed health care debate. The group has been empowered by the addition of Mr. Mulvaney to the senior White House staff, and Mr. Trump's disengagement from policy details, coupled with his intense desire to score a win after a rocky start to his presidency.
Mr. Obama stepped into the fray on Thursday with a lengthy defense of his law on the seventh anniversary of its signing, and a call for bipartisan improvements.
''I've always said we should build on this law, just as Americans of both parties worked to improve Social Security, Medicare, and Medicaid over the years,'' he wrote in a mass email to followers. ''So if Republicans are serious about lowering costs while expanding coverage to those who need it, and if they're prepared to work with Democrats and objective evaluators in finding solutions that accomplish those goals -- that's something we all should welcome.''
The Affordable Care Act requires insurers to provide ''essential health benefits'' in 10 broad categories, including maternity care, mental health care, addiction treatment, preventive services, emergency services and rehabilitative services.
Mr. Spicer defended the removal of the ''essential health benefits'' regulations, saying that it would accomplish Mr. Trump's stated goal of reducing health care costs. ''Part of the reason that premiums have spiked out of control is because under Obamacare there were these mandated services that had to be included,'' Mr. Spicer said.
Family planning groups and advocates for women's rights criticized Republican plans to roll back these requirements.
''Paul Ryan and his House members are willing to sell out the moms of America to pass this bill,'' said Dawn Laguens, an executive vice president of the Planned Parenthood Federation of America.
Conservatives say the mandates, as interpreted in rules issued by the Obama administration, add to the costs of health insurance and make it difficult for insurers to offer lower-cost options to meet consumers' needs.
Democrats say that the purpose of insurance is to share risk, and that without federal requirements, insurers would once again offer bare-bones policies. Before the Affordable Care Act took effect, maternity coverage was frequently offered as an optional benefit, or rider, for a hefty additional premium.
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URL: http://www.nytimes.com/2017/03/23/us/politics/health-republicans-vote.html
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November 14, 2014 Friday
Facts & Figures: Americans Like Their 'Obamacare'
BYLINE: THE EDITORS
SECTION: OPINION
LENGTH: 126 words
HIGHLIGHT: Seventy-one percent of survey respondents said their coverage was good or excellent.
A large majority of Americans say they like the insurance coverage they obtained through government exchanges, which were set up by the Affordable Care Act.
Via Politico
With the second round of Obamacare enrollment set to begin on Saturday, 71 percent said their coverage through the exchanges was good or excellent, according to a Gallup poll released Friday. Another 19 percent said the coverage was fair, while 9 percent rated it poorly.
The pollster notes that these marks are comparable to all who have health insurance. However, those newly insured through the exchanges are more satisfied with the cost of health care - with 75 percent saying so - versus 61 percent of all insured respondents who said they were satisfied with the cost of health care.
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October 20, 2015 Tuesday
The New York Times on the Web
Many Low-Income Workers Say 'No' to Health Insurance
BYLINE: By STACY COWLEY
SECTION: Section ; Column 0; Business/Financial Desk; Pg.
LENGTH: 1390 words
JACKSONVILLE, N.C. -- When Billy Sewell began offering health insurance this year to 600 service workers at the Golden Corral restaurants that he owns, he wondered nervously how many would buy it. Adding hundreds of employees to his plan would cost him more than $1 million -- a hit he wasn't sure his low-margin business could afford.
His actual costs, though, turned out to be far smaller than he had feared. So far, only two people have signed up.
''We offered, and they didn't take it,'' he said.
Evidence is growing that his experience is not unusual. The Affordable Care Act's employer mandate, which requires employers with more than 50 full-time workers to offer most of their employees insurance or face financial penalties, was one of the law's most controversial provisions. Business owners and industry groups fiercely protested the change, and some companies cut workers' hours to reduce the number of employees who would be eligible.
But 10 months after the first phase of the mandate took effect, covering companies with 100 or more workers, many business owners say they are finding very few employees willing to buy the health insurance that they are now compelled to offer. The trend is especially pronounced among smaller and midsize businesses in fields filled with low-wage hourly workers, like restaurants, retailing and hospitality. (Companies with 50 to 99 workers are not required to comply with the mandate until next year.)
''Based on what we've seen in the marketplace, we're advising some of our clients to expect single-digit take rates,'' said Michael A. Bodack, an insurance broker in Harrison, N.Y. ''One to 2 percent isn't unusual.''
Nationwide, the Affordable Care Act has significantly reduced the number of Americans without health insurance. Around 10.7 percent of the country's under-65 population was uninsured in the first three months of this year, down from 17.5 percent five years earlier, according to the National Health Interview Survey, a long-running federal study. Some 14 million previously uninsured adults have gained coverage in the last two years, the Obama administration estimates.
Most of those gains, though, have come from a vast expansion of Medicaid and from the subsidies that help lower-income people buy insurance through federal and state exchanges. Workers who are offered affordable individual coverage through their employers -- a group that the employer mandate was intended to expand -- are not eligible for government-subsidized insurance through the exchanges, even if their income would otherwise have qualified them.
But for those trying to get by on near-minimum wages, a plan that qualifies as ''affordable'' can still seem far out of reach.
That is the case for many of Mr. Sewell's workers. He employs 1,800 people at the 26 Golden Corral franchises he owns in six Southern and Midwestern states, and previously offered insurance only to his salaried management staff. In January, when the employer mandate took effect, he made the same insurance plan, with a bigger employer contribution, available to all employees working an average of 30 or more hours a week.
Running the math on his plan -- a typical one for the restaurant industry -- illustrates why a number of low-wage workers are falling through gaps in the Affordable Care Act.
The annual premium for individual coverage through the Golden Corral Blue Cross Blue Shield plan is $4,800. Mr. Sewell pays 65 percent for service workers, leaving them with a monthly cost of $140.
The health care law defines affordable employer-sponsored insurance as that priced at 9.5 percent or less of an employee's annual household income for individual coverage. (Because employers do not know how much money their workers' relatives make, there are several ''safe harbors'' they can use for compliance, including basing their calculation on only their own employees' wages.) Mr. Sewell's insurance meets the test, but $65 per biweekly paycheck is more than most of his workers are willing -- or able -- to pay for insurance that still carries steep out-of-pocket costs, including a $2,500 deductible.
Clarissa Morris, 47, has been a server at the Golden Corral here for five years, earning $2.13 an hour plus tips. On a typical day, she leaves the restaurant with about $70 in tips. Her husband makes $9 an hour at Walmart but has been offered only a part-time schedule there, without benefits. Their combined paychecks barely cover their rent and daily essentials.
''It's either buy insurance or put food in the house,'' she said. On the rare occasions that she gets sick, she visits a local clinic with sliding-scale fees. It costs her $25 for a visit, and $4 to fill prescriptions at Walmart.
Brad Mete, the managing partner of Affinity Resources, a staffing agency in Dania Beach, Fla., began offering insurance this year to most of his workers only because the law required it. He said the alternative, paying a penalty of about $2,000 per full-time employee, was unthinkable, ''That would put us out of business, in one swoop.''
Trying to persuade his hourly workers to buy the insurance is ''like pulling teeth,'' he said. His company's plan costs $120 a month, but workers making about $300 a week are reluctant to spend $30 of it on insurance.
The employer mandate has not yet had any noticeable effect on the number of workers enrolled in employer-sponsored health plans, according to a survey by Mercer, a human resources consulting firm. Most of the newly eligible appear to be obtaining coverage elsewhere, such as through the plan of a parent or spouse, or are continuing to go without, said Tracy Watts, a Mercer consultant.
A study by ADP, the payroll processing giant, found an income tipping point at which most employees who are eligible for health insurance will buy it: $45,000 a year.
Workers making $15,000 to $20,000 a year buy employer-sponsored individual insurance when it is offered only 37 percent of the time. That rate rises at every income increment ADP studied until $45,000, when it reaches 82 percent and levels off. Further income gains have virtually no effect on the rate, ADP found.
The study was conducted in 2013, before many of the Affordable Care Act's provisions took effect, but ADP's recent figures do not indicate significant changes in that pattern, according to Christopher Ryan, an ADP research executive.
Low participation can pose problems for employers, especially smaller ones. Insurers are reluctant to sell policies to companies with low enrollment, because they fear that only the sickest employees will buy coverage.
Until this year, most insurers would not cover groups that fell short of their minimum participation requirements. The Affordable Care Act struck down that policy -- a sea change for the industry -- by prohibiting minimum participation rules from being used to deny coverage to any employer with 100 or more workers. But there is a big loophole: Insurers are required to issue the policies, but they are not required to renew them.
Mario K. Castillo, a lawyer in Houston who has extensively studied the new law, said it was poorly understood in the industry, and a bureaucratic nightmare.
''They have to issue you a policy, but dropping it after one year is perfectly legal,'' he said. ''If you're in this space, you essentially have to shop for insurance every year.''
For employees, forgoing coverage can mean facing tax penalties. Ms. Morris said she was surprised by the $95 fee she had to pay this year for being uninsured in 2014. ''I had kind of heard about it, but I didn't think it was going to kick in until later,'' she said.
Around 7.5 million taxpayers paid the fine, according to a preliminary report by the Internal Revenue Service. That is significantly more than the three million to six million the government had forecast.
Low-income, full-time workers like Ms. Morris may prove to be some of the hardest people to bring into the ranks of the insured, said Gary Claxton, a vice president at the Kaiser Family Foundation, which conducts an annual study on employer health benefits.
''This is one of the outcomes of trying to keep employer-based coverage in place,'' Mr. Claxton said. ''These are folks that didn't have coverage before, and they're not being given much help to get coverage now.''
URL: http://www.nytimes.com/2015/10/20/business/many-low-income-workers-say-no-to-health-insurance.html
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December 3, 2013 Tuesday
October Medicaid Applications Far Outpace Enrollment Through Exchanges
BYLINE: Robert Pear
SECTION: US
LENGTH: 397 words
HIGHLIGHT: Of those who applied and were found eligible for the Medicaid or CHIP, slightly more than half were in states that have decided to expand Medicaid, as permitted under the Affordable Care Act, while 48 percent were in states that have not expanded Medicaid.
WASHINGTON - The Obama administration said Tuesday that 1.46 million people had applied and been found eligible for Medicaid or the Children's Health Insurance Program in October, far more than had selected a private health plan in the new insurance marketplaces.
Of those found eligible for the Medicaid or CHIP, slightly more than half were in states that have decided to expand Medicaid, as permitted under the Affordable Care Act.
But 48 percent of the people found eligible for the programs - 697,000 people - were in states that have not expanded Medicaid.
The new health care law has produced many changes in the way states assess eligibility for Medicaid, and it provided money to states to upgrade antiquated computer systems. These changes, combined with publicity around the rollout of the federal law this fall, apparently contributed to increases in the number of applications for Medicaid and in the number approved.
"In October, in states that are fully participating in the expansion of Medicaid coverage made possible by the law, we've seen a more than 15 percent jump in applications compared with the average monthly enrollment in July through September,'' the Department of Health and Human Services said. "This shows a real need and desire for coverage for low-income Americans.''
The report confirms expectations that many people who were eligible for Medicaid but not enrolled would come forward and seek coverage, even in states not expanding Medicaid.
For example, about 370,000 people were found eligible for Medicaid or CHIP last month in four states that have not expanded Medicaid: Florida (165,000), North Carolina (59,000), Pennsylvania (72,500) and South Carolina (73,300).
By contrast, in October, just 26,800 people selected private health plans in the new federal exchange, and 79,400 chose private plans through exchanges run by states.
States have decades of experience running Medicaid and carrying out changes in eligibility. In addition, since Medicaid is one of the biggest programs in state budgets, state Medicaid directors are often skilled, experienced managers, and their operation of the program is closely supervised by governors in almost every state.
The insurance exchanges, on the other hand, are entirely new, as are the computer systems, and congressional investigators have found huge deficiencies in management of the federal exchange.
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January 27, 2017 Friday
Late Edition - Final
Health Law Ads Canceled Days Before Key Deadline
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 375 words
WASHINGTON -- The Trump administration is pulling back advertisements that encourage people to sign up for health insurance under former President Barack Obama's health care law.
The ads were to have run in the next few days of the annual open enrollment period, which ends on Tuesday. In the last few years, large numbers of consumers signed up just before the deadline.
Under the Affordable Care Act, people who go without insurance are subject to tax penalties. But President Trump and Republicans in Congress are determined to repeal the law, including provisions that require most Americans to have insurance.
''The federal government has spent more than $60 million promoting the open enrollment period,'' a spokesman for the Department of Health and Human Services said Thursday. ''We have pulled back roughly $5 million of the final placement in an effort to look for efficiencies where they exist.''
However, the department continued to send email messages urging consumers to visit its insurance marketplace at HealthCare.gov.
''Final Deadline,'' said a typical email sent from the federal marketplace on Thursday. ''Our records show that you still need to submit a 2017 application -- before the final deadline on January 31. This year, millions of uninsured Americans have incomes that qualify them for reduced monthly costs on high-quality plans. Don't miss your final chance for 2017 health insurance.''
Since Nov. 1, more than 11.5 million people have signed up for insurance or had their coverage automatically renewed under the Affordable Care Act, federal officials said this month. More than 8.7 million of those consumers were in states that use HealthCare.gov as an enrollment portal.
Kevin J. Counihan, the former chief executive of the federal insurance exchange, accused the Trump administration of trying to ''sabotage open enrollment,'' and called the action ''outrageous.''
''We know that more young people enroll during the final days of open enrollment, but they need to be reminded of the January 31 deadline,'' Mr. Counihan said. ''Having health insurance is still law of the land. If the president and Republicans in Congress want to change that, they should come up with a plan and show it to the American people.''
URL: http://www.nytimes.com/2017/01/26/us/politics/donald-trump-obamacare-ads.html
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June 26, 2012 Tuesday
A Small Restaurant Gets a Big Increase in Health Premiums - and Misses the Tax Credit
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1064 words
HIGHLIGHT: The Herbfarm Restaurant seems like precisely the kind of small business that should benefit from the Affordable Care Act's tax credits.
With this post, The Agenda returns to our occasional series on how small companies are coping with providing health insurance. We're going to Woodinville, Wash., about a half hour north of Seattle, and The Herbfarm Restaurant. The Herbfarm, which grows many of its own ingredients in its garden and nearby fields, has also cultivated a distinguished national reputation since it opened more than two decades ago. The travel guide Frommer's once declared that the restaurant is "so famous and serves such unforgettable meals that people plan Seattle vacations around dinner here," but that hasn't made it any easier for its proprietors to provide affordable insurance to their employees.
THE OWNERS Ron Zimmerman and Carrie Van Dyck, both over 50.
THE COMPANY The Herbfarm Restaurant employs about 25 people year-round and a few more in the growing seasons. The restaurant also employs temporary "externs," visiting culinary school students who work in the restaurant and garden for a few months.
THE WAY THINGS WERE Until this year, the company paid half of the premiums and reimbursed half of the deductible cost for employees who worked 32 hours a week or more. Salaried employees were able to enroll three months after beginning work; hourly employees could join in six months. Employees who worked fewer than 32 hours could sign on to the company plans as well, but without premium reimbursement; and from time to time one or two would. Usually, about 10 people, including Mr. Zimmerman and Ms. Van Dyck, enrolled. In the plan every employee was offered last year, premiums were $363 a month, but the deductible was an astonishing $7,500.
HOW THINGS WENT AWRY Even given last year's deductible, Ms. Van Dyck said, "we've always had good coverage." In some years, the deductible has varied and the networks of doctors has changed, but the co-payment has held relatively steady. And every year, Ms. Van Dyck, who manages the restaurant's operations, has shopped for insurance with the help of an agent.
This year, her most recent insurer, Seattle-based Group Health Cooperative, demanded a 30-percent premium increase. Evidently "Group Health made a decision that they don't like small groups," Ms. Van Dyck said. (The director of Group Health's small group business offered the following statement: "We are committed to serving the small group market. We have been working with state leaders to increase the stability and affordability of insurance for small groups. We support Washington State exchange legislation that will provide more choice for small businesses and their employees.")
As for Ms. Van Dyck's agent, "his company name changed, and I'm pretty sure their priorities changed, too. Maybe they became small-group unfriendly" as well, she said. "This year he didn't bring us anything except health savings accounts, or we could stay with the same Group Health plan and pay a lot more." The H.S.A. plans required the full deductible to be met before prescription-drug benefits kicked in, and they required all family members to meet their deductibles before anyone could claim benefits. Moreover, she said, the agent insisted on extraneous requirements, like life insurance coverage. Eventually, Ms. Van Dyck found a new agent, who brought a menu of options from Aetna.
THE NEW PLAN Beginning in April, her employees could choose from three options: an H.S.A. with a $1,500 deductible (premiums are $411 a month), a plan with a high deductible ($5,000) but relatively low premiums ($310 a month), and a plan with a relatively low deductible ($1,500) but premiums that reach $450 a month. Ms. Van Dyck and Mr. Zimmerman chose the latter plan.
"I think it's really cool that we can choose the plan that's best for us," Ms. Van Dyck said, but she acknowledged that two employees, one of whom faced higher living expenses, elected to go without insurance rather than take the high-deductible plan. At the moment, eight other employees get insurance from spouses who work elsewhere, leaving 13 permanent and temporary staffers without any insurance at all.
THE PERILS OF THE SMALL GROUP The transition has not been easy. Though the restaurant has enrolled fewer than 10 employees for coverage in the past, the new policy required at least 10 employees to participate, and Ms. Van Dyck had only nine, including herself and her husband. Ultimately, to meet the enrollment requirement, she decided to fully subsidize insurance for a young employee who had declined to buy it.
At the same time, Ms. Van Dyck is no longer able to make distinctions among her employees. "We used to set our own rules, and now the insurance people are telling me who can be eligible," she said. "If I want to have the salaried people come on in three months, I have to bring everybody on in three months, and if I want to pay half the premium for full-time people, I have to pay it for everyone else, too." Now, all employees who work three-quarter time or are technically eligible to join after three months, and people who work fewer hours aren't able to sign up at all. But, she said, "our current agent says she has information about all sorts of plans that people could get on an individual basis."
THE AFFORDABLE CARE ACT Though the Herbfarm Restaurant would seem to be an ideal candidate for the health law's small-business tax credit, which phases out as the permanent payroll reaches 25 employees and the average wage reaches $50,000, the owners' accountant told them they could not take advantage of it -- the I.R.S. requires filers to calculate the credit in such way that some companies that fall below each threshold are nonetheless still disqualified. Moreover, Ms. Van Dyck said she suspected that it was uncertainty about how the new law could remake the health insurance market that caused the turmoil with her own insurer. And she acknowledged that she isn't sure how the law will affect her whether the Supreme Court upholds it or strikes it down. Nonetheless, she is hoping the Supreme Court will uphold the law. "I can't imagine that we wouldn't benefit" from the overhaul if it remains intact, she said. "The whole purpose is that we do benefit from it."
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Looking to the Affordable Care Act For Help
Further Thoughts on Why Our Health Rates Fell
My Health Insurance Rates Just Went Down Again
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May 27, 2012 Sunday
In Medicine, Falling for Fake Innovation
BYLINE: EZEKIEL J. EMANUEL
SECTION: OPINION
LENGTH: 619 words
HIGHLIGHT: We need to stop glorifying every new technology as an innovation. New matters only when it's proved better than what we had before.
THE sleek, four-armed "da Vinci" robot has been called a breakthrough technology for procedures like prostate surgery. "Imagine," the manufacturer says, "having the benefits of a definitive treatment but with the potential for significantly less pain, a shorter hospital stay, faster return to normal daily activities."
That's just the kind of impressive-sounding innovation that critics of the health care reform act say will be stifled by the new law, with its emphasis on cost control and the comparative effectiveness of new pills and devices. "Instead of encouraging innovation," wrote Senator Ron Johnson, Republican of Wisconsin, in The Wall Street Journal, "it stifles creativity."
The critics are right - if they're talking about innovations like the da Vinci robot, which costs more than a million dollars and yet has never been shown by a randomized trial to improve the outcomes of prostate surgery. Indeed, a 2009 study showed that while patients had shorter hospital stays and fewer surgical complications like blood loss when they underwent this kind of robotic surgery, they later "experienced more ... incontinence and erectile dysfunction." Similar problems are occurring with robotic surgery for other cancers.
In other words, this is a pseudo-innovation - a technology that increases costs without improving patients' health.
The Affordable Care Act will not reward this kind of innovation. But by providing incentives for hospitals to reduce infections, errors and readmissions, giving doctors more information on the comparative effectiveness of medical interventions and emphasizing preventive care over expensive services, the act will stimulate a panoply of true medical innovations. These may not be flashy; they might not even be visible to patients. But they will improve health care and lower costs.
For instance: checklists. A 2006 study showed that a five-item checklist - including hand-washing and cleaning a patient's skin - could reduce infection rates from intravenous catheters to nearly zero. According to the study, these infections cost an average of $45,000 per patient, and cause as many as 28,000 deaths among intensive care unit patients each year.
By the end of the decade, we will see many other true innovations - small and large, high-tech and non-tech. Diabetics' smartphone applications could transmit their glucose levels to doctors' offices; wireless home monitoring systems could be installed for patients with congestive heart failure; high-tech caps for drug bottles could alert patients' families if they forget to take their medications. There will also be many innovations in electronic health records. These aren't flashy robots, gleaming scanners or new pills, but there is already evidence that they will save money and improve care.
We have benefited tremendously from medical innovations like M.R.I. scanners, cardiac stents and powerful new drugs, and should celebrate the fact that the United States is the leader in developing medical technologies. But we need to stop glorifying every new technology as an innovation. "New" matters only when it's proved better than what we had before, when it prolongs survival, reduces side effects or improves quality of life - or maintains the current standard of care at a lower cost.
Health care reform may quash pseudo-innovations, but that simply directs capital and creativity away from technologies that don't improve outcomes or lower costs and toward ones that do. That should not be confused with killing innovation.
The End of Health Insurance Companies
Spending More Doesn't Make Us Healthier
In India, a Small Pill, With Positive Side Effects
For Medicare, We Must Cut Costs, Not Shift Them
Thinking Outside the Bus
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July 16, 2013 Tuesday
A Bakery Is Relieved to Have the Employer Mandate Delayed
BYLINE: JULIE WEED
SECTION: BUSINESS; smallbusiness
LENGTH: 619 words
HIGHLIGHT: So far, the insurance plans Rachel Shein has reviewed have not seemed terribly attractive for her business.
With President Obama pushing back an important start date for the Affordable Care Act, giving companies with 50 or more full-time employees an extra year before they are required to offer health insurance to their workers, we decided to check in with Rachel Shein and her wholesale bakery, Baked in the Sun.
In March, Ms. Shein and her bakery, based near San Diego, were featured in a case study that looked at what she would have to do to comply with the new health care law. With insurance companies still developing their offerings for businesses like hers, Ms Shein was delighted to learn that the employer mandate was being delayed. "I was thrilled when I heard we had the extra time to watch and wait," she said.
At the time the case study was written, Ms. Shein had been quite concerned about the potential effects of the law's implementation. "We saw it as a significant cost to our business, one we hadn't built into our business model," she said. Her participation in the case study led to appearances on several TV news programs, including on Fox Business and CNBC.
Initially, Ms. Shein estimated that she would have to pay $108,000 a year to include the 90 employees who are not currently covered by her company's health insurance. Her insurance broker now believes that when the final rates are published for next year, the cost will be higher than that.
Ms. Shein, though, will have to pay for only those employees who sign up for the plan she offers, and so far, the plans she has seen have not seemed terribly attractive. One sample plan, she said, included a $4,500 deductible, which Ms. Shein said "is too high for low-wage workers, so my employees may be better off going to the state-run market for individuals, which seems to have more options and better prices."
Insurance company offerings for businesses like hers are expected to evolve, Ms. Shein said, and she hopes better plans and choices become available, as they have on the individual exchange. Right now, Ms. Shein doesn't know the final costs or how many of her employees will sign up, so she has not been able to estimate her expenses with any confidence. "It's still very messy," she said.
The delay is an opportunity for both companies and employees, Ms. Shein said, because it gives business owners more time to shop around and workers can take the year to see what is available on the exchange before they decide if they will take company-offered insurance.
Ms. Shein is also interested to see if the managers who are covered by her company's insurance plan find a better deal on the state-run market. She said she believed all workers should have health insurance, and she and her husband have wrestled with the problem for years. In her experience, she said, many of her employees are resistant to coverage that requires an employee contribution. "They are mostly young and healthy," she said, also noting that the individual penalty for not carrying insurance is low, "and they would rather have a bit more in their paycheck than health insurance."
For now, she plans to focus on running her baking company. "The recession has made us more efficient," she said. "We've automated more and focused on the most profitable parts of the business. I can't control the insurance rates, but I can make a great espresso mocha scone."
A previous version of this post reported incorrectly that it was Congress that had delayed the employer mandate.
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The Employer Mandate Has Been Delayed. Will It Be Rewritten?
Bakery Owner Talks About Coping With Health Insurance Changes
Should a Bakery With More Than 50 Employees Offer Health Insurance?
This Week in Small Business: Hire an English Major
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October 26, 2011 Wednesday
Insurers Weigh In on Health Care Law
BYLINE: REED ABELSON
SECTION: HEALTH
LENGTH: 547 words
HIGHLIGHT: The trade group for insurers files a legal brief on the health care law.
The health insurance industry is urging the Supreme Court to decide as quickly as it can whether the federal health care law is, in fact, constitutional and to consider what other parts of the law should be struck down if the individual mandate does not pass muster.
America's Health Insurance Plans, a Washington, D.C., trade group, filed its supporting brief on Tuesday about the case. The group represents the nation's health insurance companies, many of which oppose crucial provisions of the Affordable Care Act signed into law by President Obama last year.
The group argued that insurers need to know as soon as possible if the new law will be upheld. because businesses need to "make and implement numerous critical decisions now to ensure their ability to comply as requirements come into effect in the coming years."
Many of the law's most sweeping provisions go into effect in 2014. The Obama administration says the law is constitutional and has asked the Supreme Court to hear the case quickly. Several lower courts have issued differing opinions on the law, which was challenged in court by many states.
Right now, the insurers say they don't know if the whole law will be struck down or just parts of it or whether all of the legislation will be deemed constitutional. "All of this paralyzing uncertainty-among health plans, employers, government regulators and others - underscores the vital need for a prompt and conclusive resolution of the constitutional challenge to the individual mandate. AHIP therefore respectfully urges the court to grant review of that issue and to resolve it this term," the insurers say.
The insurers also say that without the individual mandate, which would require people to buy insurance, the law is essentially unworkable. They point out that there are concerns over adverse selection, where only the people who think they need coverage buy insurance, and cite numerous examples of failed efforts by the states.
"All of that evidence underscores the very real likelihood that implementation of ACA's market reforms in the absence of the individual mandate would confound the legislation's central goal of increasing the availability of affordable health care coverage. Congress, moreover, enacted the individual mandate in conjunction with its market reforms because it was acutely aware of the widespread difficulties that had arisen from the efforts of states to implement similar insurance market reforms without the economic counterbalance of an individual mandate," the insurers say.
Is the individual mandate constitutional? If the Supreme Court strikes it down, should the rest of the health care law be allowed to stand? Should everyone be required to have health insurance?
An earlier version of this post misstated the position taken by America's Health Insurance Plans on the overall federal health legislation. It is not asking the court to consider striking down the law altogether, but seeking consideration as to whether other pieces of the law should be overturned if the individual mandate is ruled unconstitutional.
Obama Pushes More Competition on Biologic Drugs
Study Finds Medicare Drug Plan Reduces Health Spending
This Week's Health Industry News
This Week's Health Industry News
Kaiser Permanente Opens Clinic in Washington
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January 28, 2017 Saturday
Late Edition - Final
Obamacare Sabotage
BYLINE: By VIKAS BAJAJ
SECTION: Section A; Column 0; Editorial Desk; Pg. 20
LENGTH: 307 words
The Trump administration doesn't have a plan to replace the Affordable Care Act, but it's already trying to sabotage the law. It has canceled advertisements meant to encourage people to pick insurance policies on HealthCare.gov ahead of the Jan. 31 sign-up deadline.
This is a shameless attempt to drive down enrollment, especially among young people, who tend to wait until the last minute to get insurance but who are essential to the program because they tend to be healthier than older people and thus help spread the cost. Lower enrollment gives President Trump more ammunition in his fight against what he calls ''the failed Obamacare disaster.''
He and congressional Republicans have pledged to replace the law. And based on what lawmakers and Mr. Trump's choice to run the Department of Health and Human Services have said, the replacement could be a much inferior law that takes insurance away from millions and leaves others with bare-bones policies.
As of Christmas Eve, more than 11.5 million people had signed up on the federal and state health insurance exchanges, up nearly 300,000 from a comparable period a year earlier. The Obama administration had predicted total sign-ups of 13.8 million by the end of January.
The Trump administration says that by canceling the ads they are simply finding ''efficiencies where they exist.'' But officials who worked on the Affordable Care Act until just before the inauguration say that the ads had already been paid for. Even if some or all of the $5 million spent on those ads is refunded to the government, canceling them at this late stage is counterproductive and could prove very costly to the health care system and to people who don't get insurance.
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URL: http://www.nytimes.com/2017/01/27/opinion/obamacare-sabotage.html
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August 21, 2012 Tuesday
Late Edition - Final
Investors In Health Care Seem to Bet On Incumbent
BYLINE: By ANDREW ROSS SORKIN;
SECTION: Section B; Column 0; Business/Financial Desk; DEALBOOK; Pg. 1
LENGTH: 891 words
Who is going to win the presidential election?You might want to ask Mark T. Bertolini. He just bet $5.7 billion on President Obama.
Mr. Bertolini is the chief executive of Aetna, which on Monday agreed to acquire Coventry Health Care, a huge provider of Medicare and Medicaid programs. His $5.7 billion bet makes a lot of sense if you believe that the Affordable Care Act - otherwise known as Obamacare - will not be repealed.
Mitt Romney has pledged to repeal the act "on my first day if elected," so any gamble that Obamacare stays intact could be fairly described as a wager that President Obama will remain in office.
At a time when so many in the business community appear to be supporting Mr. Romney, it is telling that some businessmen and investors expect a different result - and are wagering more than rhetoric; they are staking their wallet on it.
It may be counterintuitive, but with the Standard & Poor's 500 up 9.5 percent in the last three months and the stock market over all at its highest point since the financial crisis, there is an argument to be made that investors writ large may be helping the incumbent to win. Intrade, an online market that allows investors to bet on political outcomes and other world events, shows that President Obama is favored to win, 57.3 percent to 42 percent.
"The best single predictor of presidential re-election results that we found was the percentage change in the stock market during the three years that preceded Election Day," Deepak Goel of the Socionomics Institute said in February when he released a study that was recently highlighted by Reuters. The study said that recent performance of the stock market was more important than gross domestic product, inflation and unemployment.
At a minimum, the stock market, which is an indicator of future earnings, seems to be in disagreement, at least somewhat, with the steady drumbeat of C.E.O.'s and investors who have said that President Obama's administration, in the words of Daniel Loeb, the outspoken activist hedge fund investor, "is openly hostile to most businesses and unable to articulate or implement policies to spark growth and reduce unemployment."
Mr. Loeb is a frustrated Obama voter who now backs Mr. Romney.
But take a look at some of his most recent investments in the health care field. In the last quarter, he reported in Securities and Exchange Commission filings, he picked up shares of Aetna, Cigna, Humana, UnitedHealth and WellPoint, among others. All of those companies stand to benefit while Obamacare remains in force; a repeal of the bill could send those shares reeling.
Mr. Bertolini of Aetna insisted on Monday that the deal was not dependent on who wins the White House. But he has to say that. If he believed Mr. Romney was going to win and he still wanted to buy Coventry, he would have waited until after the election and bought it at a sharp discount.
In a note to investors on Monday about Aetna's Coventry deal, an analyst at Barclays explained the rationale of it plainly as a way of "strategically positioning themselves to capitalize on further gains which may arise as a result of the election and health care reform."
Aetna is not the only company to make a bet on the White House. WellPoint agreed to acquire Amerigroup for $5 billion in July, just a little over a week after the Supreme Court's decision to uphold the Affordable Care Act. Before that, Cigna paid $3.8 billion for HealthSpring in another bet on the expansion of Medicaid and Medicare.
Companies like Aetna, WellPoint and Cigna have all gravitated to rivals with a foothold in government-sponsored programs because the prevailing view is that margins for private customers are going to steadily erode. According to Aetna on Monday, the acquisition of Coventry will "substantially increase Aetna's Medicaid footprint, creating more opportunity to participate in the expansion of Medicaid and to pursue high acuity positions as they move into managed care." Aetna's revenue from the government will jump to 30 percent from 23 percent.
In fairness, it is possible to argue that the election will be immaterial to the future of the Affordable Care Act. Even if Mr. Romney wins the presidency, depending on which parties are in the House and Senate, the act may be impossible to roll back.
"Some will argue that with the election just over two months away, the company could have been more prudent in its timing," the Barclays analyst wrote. "Our take is that the election, reform and other potential legislative issues will have little impact on this transaction."
David Einhorn of Greenlight Capital recently made the contrarian case that companies like Cigna would actually do better if the law were to be repealed, ostensibly because of the margin compression that is likely as a result of the new law.
"While the stocks are already cheap, there is the additional unpriced upside in the possibility that the election changes the political landscape, resulting in a possible modification or repeal of Obamacare," he wrote in a letter to investors last month.
Still Mr. Einhorn, through smarts or luck, made a big investment in Coventry in the last quarter. With the sale to Aetna, irrespective of his investment thesis, Mr. Einhorn's firm just made about $72 million.
This is a more complete version of the story than the one that appeared in print.
URL: http://dealbook.nytimes.com/2012/08/20/investors-in-health-care-seem-to-bet-on-incumbent/
LOAD-DATE: August 21, 2012
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GRAPHIC: PHOTO: Mark Bertolini is the chief executive of Aetna, which agreed to acquire Coventry Health Care, a provider of Medicare programs. (PHOTOGRAPH BY ANDREW HARRER/BLOOMBERG NEWS) (B4)
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March 26, 2012 Monday
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Fighting to Control the Meaning of ''Obamacare''
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 687 words
On Monday, the Supreme Court will begin three days of arguments over the constitutionality of the Affordable Care Act. The act is often called ''Obamacare,'' primarily by Republicans, as a term of disdain. Democrats have tried to limit the term's use to reshape perceptions, but that has been a tough sell. Grant Barrett, a vice president for the American Dialect Society, says it is almost impossible to persuade people to discontinue the use of a political word. ''It's an invitation to have your heart broken. You forbid it, and they start writing it on the bathroom stalls.'' Now Democrats seem to be embracing the term, launching a Twitter campaign that seeks to build positive associations for it.
2007
MARCH Jeanne Schulte Scott, a lobbyist, writes in the journal Healthcare Financial Management: ''We will soon see a 'Giuliani-care' and 'Obama-care' to go along with 'McCain-care,' 'Edwards-care,' and a totally revamped and remodeled 'Hillary-care' from the 1990s.''
MAY At a campaign speech in Iowa, Mitt Romney criticizes Democratic health care plans, saying, ''The path of Europe is not the way to go. Socialized medicine. Hillarycare. Obamacare.''
2008
APRIL 30 A spokesman for FreedomWorks, a group affiliated with the Tea Party movement, writes on the group's blog: ''Barack Obama is busy promoting his own version of HillaryCare. You can call it ObamaCare.'' MAY At a campaign speech in Iowa, Mitt Romney criticizes Democratic health care plans, saying, ''The path of Europe is not the way to go. Socialized medicine. Hillarycare. Obamacare.''
2009
JULY 8 Quoting an editorial in The Wall Street Journal, Roy Blunt of Missouri, then a congressman, and Senator Jon Kyl of Arizona enter the word into the Congres-sional Record for the first time.
2010
MARCH 23 Mr. Obama signs the Affordable Care Act into law.
DECEMBER The Department of Health and Human Services buys advertising on Google so that a link to its web site, healthcare.gov, appears at the top of searches for ''Obamacare.'' An official tells Politico that this is part of an effort to ''get accurate informa-tion to people about the new law.''
2011
FEB. 11 Representative John Conyers Jr. of Michigan says that while opponents use ''Obamacare'' in a derogatory sense, he also uses it because ''it's going to go down in history as a major accomplishment of the president's.''
JAN. 7 Representative Steve King of Iowa uses ''Obamacare'' more than 60 times in a speech. In the Congressional Record, Mr. King has used the word nearly five times as often as any other lawmaker.
FEB. 18 Representative Debbie Wasserman Schultz of Florida argues against the use of ''Obamacare'' on the House floor. ''It is meant as a disparaging reference to the president of the United States, and it is clearly in violation of the House rules against that.''
JUNE 12 The Republican presidential candidate Tim Pawlenty uses ''Obamneycare'' to link the plan to one Mr. Romney signed as governor of Massachusetts.
AUG. 15 Mr. Obama uses the word in a speech, adding, ''I have no problem with people saying 'Obama cares.' I do care. If the other side wants to be the folks who don't care? That's fine with me.''
ON THE CAMPAIGN TRAIL Republican candidates use ''Obamacare'' to fire up the base, promising to repeal the law.
Bachmann 236
Romney 84
Santorum 78
Gingrich 49
Uses of ''Obamacare'' in debates, television interviews and major speeches from May 1, 2011, to March 11, 2012, (or until each candidate dropped out), as transcribed by Federal News Service.
OCTOBER Democrats object to the use of the term ''Obamacare'' in mailings paid for with Congres-sional funds, saying that it violates a rule against using the mailings for political reasons.
2012
MARCH 23 The Obama campaign posts on Twitter, ''If you're proud of Obamacare and tired of the other side using it as a dirty word, complete this sentence: #ILikeObamacare because...''
MARCH Number of times ''Obamacare'' was used each month by members of Congress as recorded in the Congressional Record. MARCH Number of times ''Obamacare'' has been used from March 1 to 23, according to transcripts kept by ShadowTV.
Fox News 320
MSNBC 180
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ShadowTV (TV counts)
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May 27, 2013 Monday
Late Edition - Final
Partisan Gridlock Thwarts Effort to Alter Health Law
BYLINE: By JONATHAN WEISMAN and ROBERT PEAR
SECTION: Section A; Column 0; Business/Financial Desk; Pg. 1
LENGTH: 1459 words
WASHINGTON -- When he talks to Republicans in Congress, Scott DeFife, a restaurant industry lobbyist, speaks their language: President Obama's health care law is a train wreck well down the track. There will be collateral damage if changes are not made. Friends of the industry cannot sit back and let that happen.
Speaking to Democrats, he puts on his empathy hat: The Affordable Care Act is the law of the land. Its goal of universal insurance coverage is laudable, but its unintended consequences will hurt the cause.
Almost no law as sprawling and consequential as the Affordable Care Act has passed without changes -- significant structural changes or routine tweaks known as ''technical corrections'' -- in subsequent months and years. The Children's Health Insurance Program, for example, was fixed in the first months after its passage in 1997.
But as they prowl Capitol Hill, business lobbyists like Mr. DeFife, health care providers and others seeking changes are finding, to their dismay, that in a polarized Congress, accomplishing them has become all but impossible.
Republicans simply want to see the entire law go away and will not take part in adjusting it. Democrats are petrified of reopening a politically charged law that threatens to derail careers as the Republicans once again seize on it before an election year.
As a result, a landmark law that almost everyone agrees has flaws is likely to take effect unchanged.
''I don't think it can be fixed,'' Senator Mitch McConnell of Kentucky, the Republican leader, said in an interview. ''Everything is interconnected, 2,700 pages of statute, 20,000 pages of regulations so far. The only solution is to repeal it, root and branch.''
Senator Max Baucus, Democrat of Montana and one of the law's primary authors, said: ''I'm not sure we're going to get to the point where it's time to open the bill and make some changes. Once you start, it's Pandora's box.''
As the clock ticks toward 2014, when the law will be fully in effect, some businesses say that without changes, it may be their undoing.
''Are we really going to put the private sector in a situation where there's a real potential mess for posturing points?'' Mr. DeFife asked.
This is not the usual way ambitious laws are carried out, but given the politics of the Affordable Care Act, ''we cannot use any of the normal tools to resolve ambiguities or fix problems,'' said Sara Rosenbaum, a professor of health law and policy at George Washington University.
The enactment of Medicare in 1965 was followed by changes in 1967, and again in 1972. In November 1986, President Ronald Reagan signed a landmark immigration bill that offered legal status to many unauthorized immigrants. Two years later, Congress made dozens of ''technical corrections.''
The Social Security Act of 1935 was followed by the family protection program of 1939, which clarified that benefits could be claimed not just by retirees but also by dependents and survivors of covered workers.
Three years after the Affordable Care Act was enacted, an extensive list of possible fixes and clarifications has piled up. For example, Families USA, a liberal advocacy group and strong supporter of the law, would like to see more money to pay for ''navigators'' to help enroll the uninsured in the new health care marketplaces.
One provision of the statute allows low-income workers to opt out of employer-sponsored care -- and into federally subsidized exchanges -- if their share of the premium for workplace insurance tops 9.5 percent of household income. But that is calculated based on the individual worker's costs, not the total family's costs, said Ronald F. Pollack, the executive director of Families USA. It is a ''glitch,'' he said, that should easily be fixed.
But it will not be, lawmakers and lobbyists say. ''I don't believe in this Congress, anything of real substance is likely to be passed,'' Mr. Pollack said.
Senators Richard M. Burr of North Carolina and Susan Collins of Maine, both Republicans, are trying to modify the law, to make it easier for small and midsize businesses to comply.
''Listen, this is statute,'' Mr. Burr said with a tone of exasperation. ''The president's not going to sign a repeal bill. I think it's prudent to try'' to make changes.
But they are facing the same hands-over-the-ears reluctance that business lobbyists and others are finding. The last consideration of the health care law came on May 16, when the House voted to repeal it, the 37th time the House has voted to do so. Those bills have died in the Senate, which is controlled by Democrats.
A coalition of large retailers, restaurant chains and temporary staffing companies, along with their powerful Washington trade associations, says it accepts the pillars of the law. But the group, calling itself Employers for Flexibility in Health Care, or E-Flex, is pressing for significant changes.
The law's definition of a full-time worker has to be raised from someone working 30 hours a week, E-Flex says, noting that restaurants, retailers and other businesses are already looking at cutting many employees' hours to 29 to avoid having to offer the health care coverage mandated by the law. The group wants the definition raised to 40 hours. They also say that the definition of a large employer -- with all that entails for the requirements for health insurance -- needs to rise from 50 full-time employees or ''full-time equivalents,'' which could be a combination of several part-time workers.
They would also like a grace period into 2014 to comply with the law before penalties are assessed for not offering insurance that comports with the law's mandates. And they want Congress to drop a provision requiring the automatic enrollment of new employees into a health care plan for any company with more than 200 full-time workers.
''Key definitions in the law must be changed,'' Marshall L. Conrad, chairman of Libby Hill Seafood Restaurants in Greensboro, N.C., pleaded at a recent Congressional hearing.
Health insurers are focused on another goal: repealing a new tax on insurance companies that takes effect next year. The tax is expected to raise more than $100 billion over 10 years. Insurers say the cost will be passed on to consumers and businesses in the form of higher premiums.
Concerns over the law's fine print are shared even among some of its architects. As the Affordable Care Act neared completion, the Obama administration and some Democrats in Congress drafted a proposed compromise to resolve differences between the House and Senate versions and smooth rough edges. Under that version, the marketplaces that people would be able to use next year to buy insurance, often at subsidized rates, were going to be national in scope, not state by state.
A provision that takes back subsidies if someone's income rises in a year was going to be softened. According to a former White House official involved in the drafting, Democrats debated the 50-employee definition for large businesses and were open to additional flexibility for seasonal workers and teenage employees.
That all disappeared when Massachusetts elected Scott Brown to the Senate in January 2010. The Democrats lost their filibuster-proof majority. House Democratic leaders saw no alternative but to accept the Senate-passed bill as written, with some changes to follow in a hastily drafted bill that passed under rules that prohibited a filibuster.
As a result, a back-room conference, where changes could be considered in private, never happened. Consequently, said E. Neil Trautwein, a health care lobbyist for the National Retail Federation, ''the edges don't quite line up.''
''We're beyond caring who provides employer relief at this point,'' he said. ''We just want the relief.''
The obstacles are huge, beginning, Republicans say, with President Obama, who has publicly said employers face no significant problems carrying out the legislation.
''For the 85 to 90 percent of Americans who already have health insurance, this thing has already happened, and their only impact is that their insurance is stronger, better, more secure than it was before. Full stop. That's it. They don't have to worry about anything else,'' the president told reporters last month.
Many pro-business Republicans appear no more receptive. Senator Johnny Isakson, Republican of Georgia, acknowledged the push to change the 30-hour rule for full-time workers and the 50-employee threshold for large businesses. But he said raising the hour cutoff to 35 would anger some other groups of employers.
''The reality of the ACA being on the doorstep of becoming law is it's going to begin collapsing under its own weight,'' Mr. Isakson said. ''I'm not so sure there's enough individual fixes to make the law more manageable.''
URL: http://www.nytimes.com/2013/05/27/us/politics/polarized-congress-thwarts-changes-to-health-care-law.html
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GRAPHIC: PHOTOS: ''The only solution is to repeal it, root and branch,'' said Senator Mitch McConnell, Republican of Kentucky, the minority leader. (PHOTOGRAPH BY DREW ANGERER FOR THE NEW YORK TIMES)
Unlike many Republicans, Senator Richard Burr of North Carolina is trying to modify the law. (PHOTOGRAPH BY WIN McNAMEE/GETTY IMAGES) (B2)
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December 24, 2016 Saturday
Late Edition - Final
Republicans Are in Denial on Health Care
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 18
LENGTH: 595 words
Republican critics of the Affordable Care Act have long described it as a house of cards on the verge of collapse. And they continue to be wrong. A record number of people have signed up for health insurance for 2017 on the federal exchanges created by the 2010 law.
Nearly 6.4 million people had signed up for coverage as of Monday, which is about 400,000 more than at a similar point last year. Among them were two million people who did not participate in 2016, some of whom might have previously been covered through an employer. The number of enrollees does not include many millions of people whose policies will be automatically renewed or who live in states like California, Minnesota and New York that have their own marketplaces.
By the time open enrollment ends early next year, the Department of Health and Human Services estimates 13.8 million people will have signed up nationwide. The percentage of Americans without insurance is steadily declining, hitting a record low of 9.1 percent in 2015, the most recent year reported.
If President-elect Donald Trump and Republican leaders in Congress carry out their promise to repeal the law, they will be taking away health insurance from millions of people -- the A.C.A. also expanded Medicaid to cover about 14 million more low-income and poor people.
When the Obama administration announced in October that premiums would rise by 25 percent on average for midlevel plans on the federal exchanges, Republicans predicted that this would doom the system. They ignored the fact that most people would not have to pay more because federal subsidies would rise to account for the higher premiums charged by private insurers. About 77 percent of people eligible for the coverage on the exchanges can find policies for $100 a month or less.
Still, the cost of insurance, deductibles and co-payments is too high for many people, especially middle-class families that earn too much to qualify for subsidies. But the solution is not to take away the benefits of the law but to strengthen it. Costs could be lowered if more young and healthy people were encouraged to sign up to spread costs over a larger pool of people.
There is growing evidence that the law is working in other ways, too. The proportion of people who did not see a doctor because they couldn't afford to fell by at least two percentage points between 2013 and 2015 in 38 states and the District of Columbia, according to a new study by the Commonwealth Fund. That helps explain why only a quarter of Americans surveyed by the Kaiser Family Foundation said the law should be scrapped.
If lawmakers are moved by nothing else, they should think about the political costs of repealing the Affordable Care Act or crippling it with piecemeal changes. Many of the people who benefit from health reform live in states that voted for Mr. Trump and down-ballot Republicans. The Kaiser foundation estimated that residents of Florida received $5.2 billion in subsidies to buy health insurance as of last March, more than in any other state. More than 600,000 people in Ohio are enrolled in Medicaid thanks to the law. And in Texas, there are 4.5 million people with pre-existing conditions who cannot be denied coverage under the law, or charged higher prices.
Treating the Affordable Care Act as a punching bag during a political campaign is one thing. But it is quite another to destroy a law that is helping so many people.
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URL: http://www.nytimes.com/2016/12/23/opinion/republicans-are-in-denial-on-health-care.html
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The New York Times
August 20, 2016 Saturday
Late Edition - Final
U.S. Health Officials Move to End Duplicate Coverage
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 9
LENGTH: 938 words
WASHINGTON -- The Obama administration is moving to end duplicate coverage for tens of thousands of people who are enrolled in Medicaid and simultaneously receiving federal subsidies to help pay for private health insurance under the Affordable Care Act.
In the last few days, consumers around the country have received letters warning, in big black type: ''People in your household may lose financial help for their marketplace coverage.''
The unsigned letters from the federal insurance exchange tell consumers that they ''should immediately end marketplace coverage with premium tax credits for each person'' in the household who is also enrolled in Medicaid or in the Children's Health Insurance Program.
If they fail to act, the administration says, it will unilaterally cut off any financial assistance they receive to help pay insurance premiums, deductibles and other out-of-pocket medical costs.
The action, supervised by Sylvia Mathews Burwell, the secretary of health and human services, comes more than nine months after congressional investigators from the Government Accountability Office said they had discovered the potential for duplicate coverage, with double payment.
The potential is significant because low-income people can switch back and forth between Medicaid and subsidized private coverage as their circumstances change.
The Affordable Care Act created the online marketplaces, where consumers can obtain subsidies for health coverage, and it expanded Medicaid to cover millions of adults without children. The Congressional Budget Office estimates that the subsidies and the expansion of Medicaid together cost about $100 billion this year.
State officials administer the Medicaid program, but federal officials run the insurance exchanges for most states. ''It is often difficult for the two levels of government to exchange information in real time because they use different computer systems,'' said Sara Rosenbaum, a professor of health law and policy at George Washington University.
The Obama administration identified people who were receiving both Medicaid and tax-credit subsidies by comparing records of the federal marketplace with enrollment files maintained by state Medicaid agencies. A similar exercise in the spring found 88,000 people with ''dual enrollment,'' but the administration did not take action against them.
Eligibility for the two programs can change because of changes in family size, household income or other factors. Information in federal and state files may, in some cases, be out of date. State agencies do not always notify the federal marketplace when they find a person eligible for Medicaid. Indeed, beneficiaries are supposed to notify the marketplace, according to HealthCare.gov.
Republicans in Congress say that in its desire to increase enrollment, the administration has been lax in verifying consumers' eligibility for subsidies.
''Federal officials have a legal and ethical duty to be good stewards of federal dollars,'' said Representative Joe Pitts, Republican of Pennsylvania and chairman of the Energy and Commerce subcommittee on health.
But Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group, said it was not right to view consumers with Medicaid and tax credits as ''double dippers.''
''In all likelihood,'' she said, ''they are not using both forms of coverage. People may not realize they have both and may not know how to stop the marketplace coverage. There's really no advantage to double dipping here. It's not like you get money in your pocket from either of these programs. They are vendor payment programs.''
Most people who obtain insurance through the exchanges also receive subsidies to help pay the premiums, and in most cases, the Treasury pays those subsidies directly to insurance companies. Many of the same companies have contracts with state Medicaid agencies to manage care for Medicaid beneficiaries, and from 2014 to 2016, the federal government pays the full cost of coverage for newly eligible beneficiaries.
Thus, the federal government may be paying twice for the same person if the person is in both Medicaid and a subsidized insurance policy bought through the marketplace.
''We really don't want this to continue because it's basically money going down the drain,'' said Ms. Solomon, a strong supporter of the health law.
Medicaid beneficiaries generally have less income than residents of the same state who buy insurance in the marketplace. Medicaid provides many services that commercial insurers do not cover, and people usually pay less under Medicaid than they would for the same services under a subsidized private health plan.
In states that expanded eligibility, Medicaid has also been more successful than the exchanges in signing up people for insurance.
The Senate majority leader, Mitch McConnell, Republican of Kentucky, questioned the administration's plans for a marketing campaign to promote enrollment under the Affordable Care Act this fall. In a letter to Ms. Burwell on Friday, he asked how much would be spent on the campaign and where the money would come from.
Mr. McConnell suggested in the letter that the money might be better spent combating the Zika virus than ''propping up the failed Obamacare exchanges.''
Administration officials said that expanding insurance coverage and preventing the spread of Zika were both high priorities for President Obama.
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May 20, 2011 Friday
The New York Times on the Web
Nursing Home Workers
SECTION: Section ; Column 0; Editorial Desk; LETTER; Pg.
LENGTH: 227 words
To the Editor:
''Nursing Homes Seek Exemptions From Health Law'' (front page, May 16) highlights one of the great ironies of our health care system: nearly one million nursing assistants and home care aides provide essential care every day, but have no health coverage themselves.
According to P.H.I.'s latest analysis, the expansion of Medicaid under the Affordable Care Act could provide coverage to an additional 370,000 of these direct-care workers.
Demand for direct-care workers is growing dramatically as our population ages; in fact, direct care may soon be our nation's single largest occupation.
These workers provide essential services, keeping elders safe, secure and healthy. Yet unlike most workers, those who care for the elderly and people with disabilities in their homes are excluded from the minimum-wage and overtime protections of the Fair Labor Standards Act.
Our nation will not be able to build a stable elder-care work force without adequate public resources to ensure that direct-care workers receive a living wage and health coverage. Simply maintaining the status quo by exempting nursing homes from the requirements of the Affordable Care Act is not a solution.
CAROL REGAN Washington, May 16, 2011
The writer is director of health care for health care workers and government affairs director at P.H.I. (Paraprofessional Healthcare Institute).
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The New York Times
February 5, 2015 Thursday
Late Edition - Final
Two Million Signed Up for Insurance on Exchange
BYLINE: By ANEMONA HARTOCOLLIS
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 20
LENGTH: 583 words
About two million New Yorkers have signed up for insurance under the Affordable Care Act, with three out of every four of them poor enough to qualify for Medicaid, according to figures released Wednesday by the Cuomo administration.
While Gov. Andrew M. Cuomo heralded the overall numbers as a sign of the success of the program, having such a large proportion on Medicaid, which is funded by the government, could impose a heavy new burden on public finances.
But insurance experts said they expected the impact of the new Medicaid enrollment to be mitigated by the greater access to health care. In other words, they said, having Medicaid coverage would give people access to primary care that could keep them from developing a chronic disease or becoming catastrophically sick and ultimately costing the system even more.
''Theoretically, could these numbers of people eventually push that Medicaid number up higher? Yes,'' James R. Tallon Jr., president of the United Hospital Fund, said on Wednesday.
But, he added: ''Having most people insured is the key to controlling long-term cost growth because it means you can manage care in a more effective way.''
By and large, experts said, those signing up for private insurance on the state's Affordable Care Act health exchange are people who were priced out of the market before. The law raised the income ceiling for Medicaid eligibility in New York and other states that accepted the expansion of the program; a family of four can now earn about $33,000 and still qualify. Many people who earn too much for Medicaid can get subsidies to help them buy private insurance.
Though Republicans in Congress have criticized the public costs and tried several times to repeal the law, which was passed in 2010, President Obama has vowed to veto any attempt to overturn it.
A new federal policy expanding the ability of immigrants to remain in the United States may further swell the insurance rolls, Mr. Tallon said. But he said the policy was probably too new to have affected this year's numbers.
Governor Cuomo also took a positive view, saying in a statement that ''these numbers are a testament to our progress in helping those without coverage find a plan that works for them.''
Mr. Cuomo has said, however, that the state needs ''a dedicated and sustainable revenue source'' to keep the exchange going. In his executive budget, he is proposing a surcharge of up to $25 a year on health insurance premiums for coverage both inside and outside the exchange.
Leslie Moran, senior vice president of the New York Health Plan Association, an insurance industry group, said Wednesday that the surcharge was ''a very bad idea.''
''Taxing insurance only makes it more costly and therefore, less affordable,'' Ms. Moran said. ''If affordable health coverage is the goal here in New York, the new 'exchange tax' should be dropped.''
Private coverage has gone up by 133,000 so far this year and Medicaid enrollment by 297,000. About 15 percent of those who bought private coverage last year have not renewed, possibly because they found the premiums too high or they obtained coverage through their employers.
Enrollment is not yet over for the year; the deadline is Feb. 15. Those who do not enroll by that date will have to wait until 2016 for coverage, unless they have experienced a life-changing event, like marriage or the birth of a child.
This is the first year that people who do not have insurance can be penalized for it on their taxes.
URL: http://www.nytimes.com/2015/02/05/nyregion/two-million-signed-up-for-insurance-on-exchange.html
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November 13, 2013 Wednesday
The Slow Death of the Employer Mandate
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 820 words
HIGHLIGHT: A Massachusetts precedent indicates that when business is given time to mount opposition, an employer mandate for health coverage may not be viable, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Students of health reform can be informed and entertained by revisiting a book by the health reform champion John E. McDonough.
As a member of the Massachusetts House of Representatives from 1985 to 1997, Mr. McDonough had worked for state health reform well before the now famous Romneycare health reform of 2006. During that time he also earned a doctorate in public health.
Like many other former legislators, he wrote a book about his experiences and relationships in office. "Experiencing Politics" (published 13 years ago) organizes his stories around social science models of the political process, including the principal-agent model and punctuated equilibrium theory.
The models are known by fancy phrases in the academic literature, but Mr. McDonough quickly brings them down to earth with explanations that are nontechnical and addressed to the general public. His stories are engaging and bring the models alive, even to social scientists who have seen the models on paper, yet may be dubious that they have much practical value.
Mr. McDonough is not trained as an economist, but usually shows good economic instincts in the book (though he does not mention that per-employee penalties and minimum wages might reduce employment among low-skill workers).
Why is politics so contentious and polarized these days? Mr. McDonough explains that there's a lot at stake: "We invest enormous authority and trust in our government" and "we give our legislatures remarkable powers to pass laws that govern our own behaviors, from the trivial to the profound."
Of particular interest today are his Chapters 6 and 7 on Massachusetts health legislation between 1988 and 1997. Mr. McDonough describes how the state's previous system of hospital rate regulation had been put in place for the purpose of controlling medical spending and how he believes it might have worked for a time.
But he says the academic studies on which he relied became outdated. "I didn't see it coming," he says, adding, "Massachusetts government lost the ability to manage its hospital regulatory system with discipline and integrity." He and other legislators concluded that "market-based contracting, organized around managed care, could correct the worst aspects of market failure, not perfectly but far better than regulation."
Mr. McDonough describes how Gov. Michael Dukakis's 1988 law sought to achieve universal coverage in Massachusetts with a legislative package that included a $1,680 penalty (per employee, per year) on employers who did not provide health coverage to their employees. Adjusted for inflation, that would be like proposing a $2,863 penalty in 2006, when Romneycare was passed with a mere $295 employer mandate.
The Dukakis package passed narrowly, and to gain legislative approval the final law delayed the employer mandate's implementation by four years. Does that sound familiar? The national Affordable Care Act was passed in 2010, with an employer mandate to begin in 2014.
Mr. McDonough describes how those four years gave Massachusetts employers time to organize their opposition. Moreover, as 1992 approached, the Massachusetts labor market was weak. Arguably both of these things happened nationally between 2010 and 2013.
As a legislator, Mr. McDonough met with business executives to respond to their concerns over health reform. He recalls one of those meetings where "sitting quietly through my presentation was the owner of a Domino's Pizza shop." The shop owner explained: "I compete against pizza stores that pay everything and everyone under the table. I pay unemployment, worker's comp, FICA, you name it, and you want to add one more thing that I have to dig up while my competitors pay none of those things? Come on."
Mr. McDonough had no reply to alleviate that concern. With a few months to go until the originally scheduled implementation, Massachusetts lawmakers decided to delay the Dukakis employer mandate for three years. It would be delayed two more times and then, in exchange for business community support for a coverage expansion for children, ultimately repealed.
On the national level, while Congress was not consulted, with six months to go before the originally scheduled implementation, the Obama administration delayed its employer mandate one year.
Although today Mr. McDonough notes the differences rather than the parallels between the Dukakis law and the Affordable Care Act, proponents of the national employer mandate should be worried that it may be approaching the end of its political life.
In the Death Spiral We Trust
Obamacare vs. Romneycare: The Labor Impact
The Economics of the Affordable Care Act
Massachusetts Employees Will Keep Their Health Plans
Health Coverage Worthy of a Senator
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December 11, 2013 Wednesday
Late Edition - Final
Obama Sees a Rebound In His Approval Ratings
BYLINE: By SHERYL GAY STOLBERG and ALLISON KOPICKI; Sheryl Gay Stolberg reported from Washington, and Allison Kopicki from New York. Megan Thee-Brenan and Dalia Sussman contributed reporting from New York.
SECTION: Section A; Column 0; National Desk; Pg. 21
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WASHINGTON -- President Obama's approval ratings, which hit his all-time low last month, have returned to where they were before the rollout of the health care law's enrollment process, but Americans still lack confidence in the White House's management of the Affordable Care Act, according to the latest New York Times/CBS News poll. The public's opinion of the law itself has improved after repairs to the enrollment website.
According to the poll, 42 percent of Americans now approve of Mr. Obama's overall performance, and 50 percent disapprove. That is not exactly good news for the president, but is better than his numbers in mid-November, after he admitted he had fumbled the rollout of the health care law's website. Then, just 37 percent approved and 57 percent disapproved in a CBS News poll.
The findings suggest that for Mr. Obama, the political fallout from the website's start-up might be over. The White House says the website, HealthCare.gov, is now functioning smoothly for most users.
But Americans do not appear to be convinced that the problems have been fixed. Just one in six Americans in the poll said the online insurance enrollment process was going very well or somewhat well.
And while more than a third perceived the website as having improved, a larger number -- 44 percent -- said it was neither getting better nor worse.
The success of HealthCare.gov -- an online marketplace where consumers are supposed to be able to shop for insurance coverage, compare prices, determine if they are eligible for subsidies and enroll in plans -- is crucial to the success of the Affordable Care Act.
Americans seem to be giving Mr. Obama a pass for the website's technical problems after it opened to the public on Oct. 1, according to follow-up interviews. Both Democrats and Republicans interviewed did fault Mr. Obama for what they viewed as flawed management decisions.
''I don't really put all the blame on the president,'' said Pete Brown, 56, a Republican from Edelstein, Ill., who said he disagreed with the health law's concept. ''I mean, Obama isn't in the day-to-day activities. But he didn't put the right leadership overseeing it to get it into place. If it was going to be done, then it should have been done well.''
Lise Colgan, 60, a Democrat from Cottage Grove, Ore., who approves of the health law, agreed. ''I think the president could have been a little more hands-on with the botched rollout,'' she said, ''but I don't blame him for technology failures.''
The law itself remains unpopular; half of the respondents disapproved of the Affordable Care Act, while 39 percent approved, the poll found. But Americans seem to view the law more favorably now than a month ago, when 61 percent disapproved and just 31 percent approved.
Several independent voters predicted in interviews that the law would become more popular as more Americans gained benefits through the law.
''It's a rough start, but anything our government has ever launched has never started out all that well,'' said Ed Stanutz, 24, an independent from Monroeville, Pa., who recently graduated from college and is looking for work. ''I think once it clears out and starts to work fine, people will begin to accept it more.
Another independent, Wayne Gottschalk, 68, who works for the Department of Veterans Affairs in Topeka, Kan., said, ''I think more people will become familiar with it, and it will be a godsend to a lot of people, and it won't be an issue within 18 months.''
The change in Mr. Obama's job-approval rating could be attributed to recent improvements seen in the way the law is being carried out.
His job-approval ratings on two other crucial issues -- the economy and foreign affairs -- have remained relatively constant since mid-November. But the poll found 41 percent of Americans approved of his handling of health care, up significantly from 32 percent last month.
The nationwide telephone poll, conducted on both landline phones and cellphones from Dec. 5 to Dec. 8, surveyed 1,000 adults and had a margin of sampling error of plus or minus three percentage points.
The results suggested a return of support among two of the president's constituencies, Democrats and the young, who seemed to have soured on his handling of health care in November.
Among Democrats, support of the president's performance of the issue jumped by 11 points from last month. Young people also appear to have returned to prior levels of support, with approval of his handling of health care up 14 points since last month among those ages 18 to 29.
Yet the troubles with the law's rollout may have wounded the president. About half of Americans say Mr. Obama is honest and trustworthy, a substantial drop from September 2012 and a figure unchanged from three weeks ago, when the website's problems dominated news reports. And about four in 10 say Mr. Obama shares their priorities for the country, a drop from when he first took office and also unchanged from three weeks ago.
Since its passage along partisan lines in March 2010, the Affordable Care Act has proved divisive, and the poll found that sentiment about the president and the health law remains largely driven by party affiliation.
URL: http://www.nytimes.com/2013/12/11/us/politics/obama-sees-a-rebound-in-his-approval-ratings.html
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March 31, 2014 Monday
An Owner Asks a Question About Offering Employees a Stipend to Buy Health Coverage
SECTION: BUSINESS; smallbusiness
LENGTH: 519 words
HIGHLIGHT: Could replacing insurance with a set sum of cash that employees can use to buy their own insurance lead to accusations of age discrimination?
I read with interest Robb Mandelbaum's post last week in which Dr. Ezekiel J. Emanuel predicted that employers will stop offering health insurance. In particular, I was intrigued by the following comment from Dr. Emanuel:
I don't understand why it's just not better if you're a small business to say, all right, everyone, I'm just going to give you X amount of dollars and let you shop in the individual market. That seems to me to be a way to go - why should a small business set up a lot of machinery around it?
This raises a question that troubled me when I did my own investigation of the Affordable Care Act, and in particular when I discovered that the law mandates that premiums for policies offered on the federal exchange rise with age. Here's the issue:
If you replace insurance coverage, which is given equally to all employees, with a sum of cash that doesn't actually buy the same amount of benefit for each of your employees, are you practicing age discrimination? I suspect it could be an issue because a set amount of money will buy less insurance for older workers. Do you compensate for this by giving your older workers a larger amount? And do you increase it each year to cover the rise in cost that the law mandates?
I'm surprised that Dr. Emanuel didn't mention this, although he said that he doesn't understand how some parts of the law work and that the administration didn't anticipate the effect of the legislation on business owners. I think he's right to ask why business owners should have to become experts in health insurance legislation, but ignoring it is really no longer an option. The Affordable Care Act has joined all of the other labor-related regulations that employers need to understand. There really is no way to run a business without spending time learning to navigate the legal environment.
My experience finding a plan for my workers and coping with my insurance company has made it tempting for me to consider dropping coverage after this year. I always hated sinking enormous amounts of time into insurance issues, and now it's way, way worse. And with the individual market reformed by the new law, I won't feel that I have done my workers a disservice if I let them buy their own coverage. But before I wash my hands of this responsibility, this is one of the problems that I would have to solve: How much would I have to offer my people in additional wages to replace this benefit?
I'm curious whether any of you have thought about this and what you plan to do. And while I'm asking, if you substitute insurance coverage with cash, would you include compensation for the taxes your employees will have to pay on the wages they will use to buy insurance? How much money are you willing to spend to get out of the insurance game?
Paul Downs founded Paul Downs Cabinetmakers in 1986. It is based outside Philadelphia.
What I Took Home From My Business in 2013
The Information We Still Need to Manage Our Health Care
What the New Health Insurance Law Means for My Workers
An Owner Figures Out How to Save on His Health Insurance
What I Needed to Understand About Health Insurance
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October 14, 2014 Tuesday
How Fast Are Small-Business Health Premiums Rising?
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1150 words
HIGHLIGHT: Many states are currently finalizing rates in the small-group market for next year. So far, the indications seem to be that the rate increases facing most employees insured through a small business will be considerably less than many predicted.
Today we return to our series exploring lingering questions small-business owners have about the Affordable Care Act. Today's question is a basic one: Will premiums for small businesses rise in 2015, and if so, how steeply?
If you asked someone in the health insurance industry earlier this year - the executives at the insurance carriers or the brokers and agents who sell their policies - the word on premiums was grim. In March, an unidentified insurance industry executive told The Hill that "everybody knows" that the way the exchange has rolled out "is going to lead to higher costs."
Then in April, a survey of insurance brokers by Morgan Stanley found that insurance premiums for small businesses were rising, on average, 11 percent, and at least 20 percent in 15 states. In Washington state, according to the report, small group rates were rising at the astounding rate of 588 percent. The report quickly became fodder for conservative media and Republican attack ads around the country.
Now it is October, and many states are finalizing rates in the small-group market for next year. And we are learning, anecdotally, that the rate increases facing most employees insured through a small business will be considerably lower than the dire predictions. By and large, it appears that the increases will be less than 10 percent. In some cases, they will be near zero - and at least one state is claiming the average rate increase will actually be a rate reduction.
The evidence is anecdotal because, as far as we can tell, nobody is systematically collecting, let alone analyzing, small-group insurance rates for next year, though in many states they are disclosed in regulatory filings that are freely available online. Several organizations are tracking rates for the individual market, most notably the accounting firm PricewaterhouseCoopers, which has a couple of staffers working nearly full time on the endeavor and has compiled average rate information in a clickable map. "The vast majority of the attention associated with the Affordable Care Act has been focused on the individual market," said Elizabeth Carpenter, a director of Avalere Health, a Washington consulting firm that has also analyzed individual market rates. "What I have not seen is anybody tracking the small-group market."
Many states publicly announce the change in premiums, up or down, as they make their final decisions on insurer rate requests for 2015. (Some states don't give themselves the authority to approve or reject proposed rates. In some states, including Texas, insurers don't have to file rates for the small-group market. And at least one state, Idaho, keeps rates secret.) But they do so without any uniformity. The rate information the states announce, and how they calculate the figures they announce, vary widely.
And how an average premium is calculated makes a big difference. For example, in Ohio, where the state government is controlled by Republicans, the Department of Insurance announced that based on the insurers' preliminary requests, the cost of small-business health plans sold by insurers participating in the marketplace created by the health law would rise by 11 percent. "It's bad news, no doubt, but it's what we expected," Lt. Gov. Mary Taylor said in the news release. "Obamacare is hitting us harder and driving our costs up significantly."
But as the Cleveland Plain Dealer pointed out, the state's figure was a simple average: It gave equal weight to each carrier's average premium, regardless of that insurer's market share, and some of the largest proposed rate increases came from very small insurers. "If the question is 'What is the typical or average rate increase in the market?' I believe market share is key," said David Axene, an actuary in Murieta, Calif.
In fact, a single large insurer, Anthem Blue Cross Blue Shield, dominates the small-group market described in Ohio's news release - and it is raising its average rate by just 5.5 percent. (According to insurance company projections made with the state insurance department, Anthem expects to have nearly 80 percent of this market in 2015. However, the small-group market in question has been arbitrarily defined. It includes all of the carriers operating on Ohio's small-group health insurance exchange, but it also includes some, though not all, of those carriers' off-exchange plans.)
With that in mind, here's what we've learned from a handful of states around the country:
Montana: In August, the state's insurance commissioner, Monica Lindeen, announced "historically low" rate increases for 2015. In the small-group market, rates for plans that comply with the Affordable Care Act's requirements for benefits and cost-sharing will go up just 1.1 percent. (This is a simple average, not a weighted one.) A spokeswoman for Ms. Lindeen, Jennifer McKee, said that plans that did not comply with the law represented "a very small percentage of the market" and would see rate increases between 9.5 and 25 percent.
New York: According to the state, premiums will rise, on weighted average, by 6.7 percent. The range of change runs from a 14.6 percent decrease to a 14.4 percent increase. Both of these insurers are among the smallest in the market.
Rhode Island: Based on the average premiums in the small group market and each carrier's current share of that market, all provided by the office of the state's health insurance commissioner, rates will go up by a weighted average of 6.3 percent.
Vermont: Blue Cross and Blue Shield of Vermont is the state's dominant small-group insurer, holding 92 percent of the market, according to state filings. The state approved a 7.7 percent rate increase for the carrier for 2015. (It had asked for 9.8 percent.) The other insurer, MVP Health Plan, will raise its premiums by 10.9 percent.
Oregon: The state insurance division announced that rates for compliant small-group plans would fall by 5.8 percent in 2015. The number represents a simple average of one type of compliant plan, a silver plan. (A silver plan pays for 70 percent of a typical person's medical costs.) Using a weighted average supplied by the office, the cost of a silver plan will fall by 1 percent next year.
One final thing to keep in mind: Premiums in the small-group market are especially volatile, so changes over a single year may not be especially meaningful. A recent study from the Robert Wood Johnson Foundation found that for companies with fewer than 100 employees, double-digit premium increases were common between 2000 and 2013.
But, the study concluded, "large increases in one year are frequently followed by much smaller increases, or even average premium decreases. This may be especially true as insurers, employers and individual purchasers navigate the new insurance environment created by the A.C.A, moving toward a more stable equilibrium situation over the first few years post reform."
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June 5, 2014 Thursday
Facts & Figures: Before and After 'Obamacare'
BYLINE: THE EDITORS
SECTION: OPINION
LENGTH: 118 words
HIGHLIGHT: The uninsured rate has declined significantly since the law took effect.
Although few Americans say the Affordable Care Act has helped them, the uninsured rate has declined significantly since the law took effect, and appears to be leveling off at around 13.4 percent.
Via Gallup
The uninsured rate so far in the second quarter of 2014 is 13.4%, with the rate in April and May as individual months also averaging 13.4%, respectively.
...
The percentage of U.S. adults lacking insurance coverage in the first two months of the second quarter of 2014 is down from 17.1% in the fourth quarter of 2013 and from the 15.6% average in the first quarter of 2014. The current 13.4% average for the second quarter of 2014 is the lowest level recorded since Gallup began tracking this measure in 2008.
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August 19, 2015 Wednesday
Late Edition - Final
A Part of Obamacare the G.O.P. Can Love
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 22
LENGTH: 436 words
The Obama administration last week announced a big increase in support for community health centers in the latest expansion of a program that has a long bipartisan history and robust bipartisan support today.
The health centers got a start under President Lyndon Johnson's war on poverty, expanded slowly over the years, and then got a huge lift from President George W. Bush, who doubled federal financing for the centers over five years and created or expanded almost 1,300 clinics in medically underserved areas. He admired the cost-effectiveness of the nonprofit centers, which treat low-income people and recent immigrants in poor urban neighborhoods and isolated rural areas and serve patients who would otherwise seek more expensive care in emergency rooms or hospitals.
The 2010 Affordable Care Act further expanded the program with increased funding over a five-year period, and the larger system of clinics is one of health care reform's most praiseworthy achievements.
Today the health centers have become the largest primary care system in the United States. They serve some 23 million patients a year in over 9,000 locations across the country. Their professional association says they save the health care system some $24 billion a year by providing timely treatment and preventive care designed to meet local needs and preferences. The government says their quality of care equals and often surpasses that delivered by other primary care providers.
Last week the Department of Health and Human Services announced that it would distribute $169 million provided by the Affordable Care Act to open 266 new health centers in 46 states, the District of Columbia and Puerto Rico. That is on top of more than 700 new health centers that have already opened as a result of the A.C.A. They were all financed by a trust fund that could not be touched for five years and by annual discretionary appropriations that can be cut at any time.
The trust fund and a related trust fund for the National Health Service Corps that supplies most of the doctors and other health professionals who serve in the community health centers were set to expire after their five-year run at the end of September.
Fortunately, in the spring, Congress by overwhelming margins extended funding for the centers and health service corps for another two years as part of legislation notable mainly for fixing a flawed Medicare payment formula for doctors and extending an important children's health insurance program. This will keep the program safe through the 2017 fiscal year but it will need to be nurtured in the years beyond.
URL: http://www.nytimes.com/2015/08/19/opinion/help-from-the-obama-administration-for-community-health-centers.html
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January 13, 2017 Friday
The New York Times on the Web
Senate Takes Major Step Toward Repealing Health Care Law
BYLINE: By THOMAS KAPLAN and ROBERT PEAR
SECTION: Section ; Column 0; Washington; Pg.
LENGTH: 1105 words
WASHINGTON -- Senate Republicans took their first major step toward repealing the Affordable Care Act on Thursday, approving a budget blueprint that would allow them to gut the health care law without the threat of a Democratic filibuster.
The vote was 51 to 48. During the roll call, Democrats staged a highly unusual protest on the Senate floor to express their dismay and anger at the prospect that millions of Americans could lose health insurance coverage.
One by one, Democrats rose to voice their objections. Senator Maria Cantwell of Washington said that Republicans were ''stealing health care from Americans.'' Senator Ron Wyden of Oregon said he was voting no ''because health care should not just be for the healthy and wealthy.''
The presiding officer, Senator Cory Gardner, Republican of Colorado, repeatedly banged his gavel and said the Democrats were out of order because ''debate is not allowed during a vote.''
The final vote, which ended just before 1:30 a.m., followed a marathon session in which senators took back-to-back roll call votes on numerous amendments, an arduous exercise known as a vote-a-rama.
The approval of the budget blueprint, coming even before President-elect Donald J. Trump is inaugurated, shows the speed with which Republican leaders are moving to fulfill their promise to repeal President Obama's signature domestic policy achievement -- a goal they believe can now be accomplished after Mr. Trump's election.
The action by the Senate is essentially procedural, setting the stage for a special kind of legislation called a reconciliation bill. Such a bill can be used to repeal significant parts of the health law and, critically, is immune from being filibustered. Congress appears to be at least weeks away from voting on legislation repealing the law.
Republicans say the 2016 elections gave them a mandate to roll back the health care law. ''The Obamacare bridge is collapsing, and we're sending in a rescue team,'' said Senator Michael B. Enzi, Republican of Wyoming and the chairman of the Senate Budget Committee. ''Then we'll build new bridges to better health care, and finally, when these new bridges are finished, we'll close the old bridge.''
Republican leaders say they will work closely with Mr. Trump developing legislation to repeal and replace the health care law, but it is unclear exactly how his team will participate in that effort.
On Wednesday, Mr. Trump said he would offer his own plan to repeal and replace the law ''essentially simultaneously.'' He said he would put forth the plan as soon as his nominee for secretary of health and human services, Representative Tom Price, Republican of Georgia, is confirmed.
The Affordable Care Act has become ingrained in the American health care system, and unwinding it will be a formidable challenge for Republicans. More than 20 million people have gained coverage under the law, though premiums have risen sharply in many states and some insurers have fled the law's health exchanges.
The budget blueprint instructs House and Senate committees to come up with repeal legislation by Jan. 27.
Senator Bob Corker, Republican of Tennessee, and four other Republicans had sought to extend that deadline by five weeks, to March 3. But late Wednesday night, Mr. Corker withdrew an amendment that would have changed the date.
''We understand that everyone here understands the importance of doing it right,'' he said. He described the Jan. 27 date in the budget blueprint as a placeholder.
Senator Rob Portman of Ohio, another Republican who sought to delay the deadline, said: ''This date is not a date that is set in stone. In fact, it is the earliest we could do it. But it could take longer, and we believe that it might.''
The House was planning to take up the budget blueprint once the Senate approved it, though some House Republicans have expressed discomfort with voting on the blueprint this week because of lingering questions over how and when the health care law would be replaced.
A vote on the measure in the House could come on Friday.
In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes.
In the parlance of Capitol Hill, many of the Democrats' proposals were ''messaging amendments,'' intended to put Republicans on record as opposing popular provisions of the Affordable Care Act. The budget blueprint is for the guidance of Congress; it is not presented to the president for a signature or veto and does not become law.
As the Senate plowed through its work on Wednesday, Republicans explained why they were determined to dismantle the health care law, and they tried to assuage concerns about the future of coverage for millions of Americans.
''This is our opportunity to keep our campaign promise,'' said Senator Roger Wicker, Republican of Mississippi. ''This is our opportunity to help the president-elect and the vice president-elect keep their campaign promises and show to the American people that elections have consequences.''
Senator Johnny Isakson, Republican of Georgia, said that while working to repeal the health care law, ''we must also talk about what we replace it with, because repealing it without a replacement is an unacceptable solution.''
Republicans do not have an agreement even among themselves on the content of legislation to replace the Affordable Care Act, the timetable for votes on such legislation or its effective date.
Senator Susan Collins, Republican of Maine, said on Wednesday that she agreed with Mr. Trump that Congress should repeal the health law and adopt a replacement plan at about the same time.
''But I don't see any possibility of our being able to come up with a comprehensive reform bill that would replace Obamacare by the end of this month,'' she said. ''I just don't see that as being feasible.'' (Ms. Collins also supported pushing back the deadline to come up with repeal legislation.)
As Republicans pursue repealing the law, Democrats contend that Republicans are trying to rip insurance away from millions of Americans with no idea of what to do next.
The Senate Democratic leader, Chuck Schumer of New York, called the Republicans' repeal plan ''irresponsible and rushed'' and urged them to halt their push to unravel the law.
''Don't put chaos in place of affordable care,'' he said.
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
URL: http://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html
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April 15, 2014 Tuesday
Facts & Figures: A Cheaper 'Obamacare'
BYLINE: THE EDITORS
SECTION: OPINION
LENGTH: 198 words
HIGHLIGHT: The Congressional Budget Office say the net cost of the law’s coverage provisions will be about $100 billion less than expected over ten years.
The Congressional Budget Office said yesterday that the Affordable Care Act should be cheaper than originally projected.
Via The New Republic
In February, the last time CBO addressed these issues comprehensively, it predicted that the net cost of the law's coverage provisions would be about $1.4 trillion over ten years. Now, CBO says, it's likely to be about $1.3 trillion, or $100 billion less.
It's actually the latest in a series of revisions, each one suggesting the law would cost less money than the previous projection had suggested. And why this latest change? It doesn't appear to be because the law will reach fewer people. CBO now expects slightly more people to end up with health insurance, at least over the long run. The CBO's primary explanation for lower costs is that health insurance premiums on the new exchanges - what the administration calls "marketplaces"- are lower than CBO had originally expected they would be.
No, 'Obamacare' Isn't Killing 2 Million Jobs
Kathleen Sebelius Was Too Cool and Too Patient
No Comment Necessary: Replacing the A.C.A. With...the A.C.A.?
Facts & Figures: Clueless on the 'Obamacare' Deadline
The Women on the Sidelines of the Hobby Lobby Case
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January 3, 2017 Tuesday
Late Edition - Final
Health Reform Could Outlast Repeal Efforts
BYLINE: By ABBY GOODNOUGH and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 3392 words
FISHERS, Ind. -- Fragments of bone and cartilage arced across the operating room as Dr. R. Michael Meneghini drilled into the knee of his first patient at a hospital here at dawn. Within an hour, the 66-year-old woman had a replacement joint made of titanium and cobalt chrome, and she was sent home the next day.
But the Obama administration was watching over her caregivers' shoulders. If, over three months, her medical costs exceeded a target amount set by President Obama's health regulators in Washington, Dr. Meneghini's employer, Indiana University Health, stood to lose money.
Such efforts to squeeze spending out of the nation's health system may well remain as Mr. Obama exits the West Wing and Donald J. Trump takes his seat in the Oval Office. The Affordable Care Act is in extreme peril, and Mr. Obama will meet with congressional Democrats at the Capitol on Wednesday to try to devise a strategy that can stave off the quick-strike repeal of the health law that Republicans plan for the opening months of the Trump administration.
But the transformation of American health care that has occurred over the last eight years -- touching every aspect of the system, down to a knee replacement in the nation's heartland -- has a momentum that could prove impossible to stop.
Expanding insurance coverage to more than 20 million Americans is among Mr. Obama's proudest accomplishments, but the changes he has pushed go deeper. They have had an impact on every level of care -- from what happens during checkups and surgery to how doctors and hospitals are paid, how their results are measured and how they work together.
''From the moment I first set foot in the Oval Office in February 2009, the president told me that the law can't be just about covering the uninsured, but that it also has to be about changing the way care is delivered,'' said Nancy-Ann DeParle, who as a White House aide helped lead the effort to pass and carry out the health law. His message, she said: ''I don't want to cover everyone and just put them in the same creaky old delivery system.''
Changes in the delivery system already affect far more people than the law's higher-profile coverage gains. To visit IU Health, the largest health care provider in Indiana, with 15 hospitals and 8,700 doctors, is to see those changes up close. Its leaders have started moving away from fee-for-service medicine, where every procedure, examination and prescription fetches a price. The emphasis now is on preventive care, on taking responsibility for the health of patients not only in the hospital, but also in the community.
Social work has become a larger part of the medical mission. Collaboration between doctors is becoming a necessity.
''I don't know who could be against it: higher quality and lower cost,'' said Ryan C. Kitchell, an executive vice president and the chief administrative officer of IU Health.
And unlike Mr. Obama's insurance coverage expansions, these changes are not in jeopardy, said Dennis M. Murphy, IU Health's president and chief executive.
''We've got to create more value in health care,'' Mr. Murphy said in an interview after Mr. Trump's election. ''That principle, I think, survives.''
During Mr. Obama's tenure, big systems like IU Health have gobbled up smaller hospitals and physician groups as the industry has consolidated, partly in response to incentives in the Affordable Care Act. Most doctors across the United States are using electronic medical records, installed in many cases with federal money provided by the economic stimulus law of 2009. The federal government and private insurers are rewarding health care providers that work together to coordinate care and avoid unnecessary expenses.
Doctors and hospitals here are obsessed with metrics, not least because under the health law, they may be rewarded or penalized based on their performance. They tally the number of medication errors, the number of patients injured in falls and the number who develop infections after certain types of surgery.
Expanding coverage is seen not as a political issue, but as a clinical and financial imperative. IU Health has more than 150 ''navigators'' who work with patients to help them get insurance, often through a Medicaid expansion authorized and funded by the health law and engineered here by Gov. Mike Pence, the vice president-elect.
''I've been a registered Republican my whole life, but I support the Affordable Care Act,'' said Dr. Gregory C. Kiray, co-chief of primary care for IU Health Physicians, ''because it allows patients to be taken care of.''
To better understand how Mr. Obama has changed health care, two reporters from The New York Times spent a week shadowing and talking to doctors, patients, executives and others at IU Health, a system that demonstrates the breadth of changes catalyzed by the Affordable Care Act.
To many IU Health employees, the pace of change can be bewildering, the new directives too numerous or burdensome.
''People feel like they are swimming in an ocean, drowning,'' said Dr. Meneghini, an orthopedic surgeon at IU Health's Saxony Hospital here in Fishers, a suburb of Indianapolis.
But the medical profession increasingly understands that painful as it is, the revolution is necessary and unstoppable.
''The national economy cannot sustain health care being as big a share of the gross domestic product as it is,'' Mr. Murphy said, uttering what once amounted to heresy for a health care provider.
'Be Thoughtfully Aggressive'
Fury over the Affordable Care Act helped jump-start the Tea Party movement and sweep Republicans into control of the House of Representatives in 2010 and the Senate in 2014. It ensured gridlock that stifled many of Mr. Obama's greatest legislative ambitions for six of his eight years in office, and it may well have played a role in the election of Mr. Trump, who attacked the law throughout his campaign.
Yet to Mr. Obama, the law remains one of his greatest achievements, said Denis McDonough, the White House chief of staff. It also has been his constant concern.
''This attention to cost and concern about cost, and even the emotional concern about cost, comes up all the time,'' Mr. McDonough said.
The Affordable Care Act gave the government sweeping authority to test new models of care, and the administration has aggressively used that power to try different ways of paying for cancer care, heart surgery, primary care and other services covered by Medicare and Medicaid.
Sylvia Mathews Burwell, who has been the secretary of health and human services since 2014, said she met with Mr. Obama early in her tenure to describe a series of payment and delivery reforms. He was so supportive, she said, that she and her team decided to undertake even more changes.
The size and speed of some of those initiatives have provoked criticism from Republicans, including Representative Tom Price of Georgia, picked by Mr. Trump to be the health and human services secretary. They say the efforts threaten the quality of care and exceed the authority of the agency overseeing Medicare by requiring doctors and hospitals to participate.
More than 170 House Republicans signed a recent letter of which Mr. Price was an author, urging the administration to ''stop experimenting with Americans' health.''
But moving aggressively to change how medical care is delivered and paid for has been important to Mr. Obama. In 2015, his administration set a goal for half of all Medicare payments to be tied to the quality, instead of the quantity, of care that doctors and hospitals provide by 2018. Mr. Obama believes that basing pay on whether a doctor visit or a medical procedure helps a patient, rather than on how much care the patient receives, will result in better care.
''What he said was, 'Be thoughtfully aggressive,''' Ms. Burwell said.
At Patients' Service and Mercy
''I started drinking soda again,'' confessed Willie Johnson, a 52-year-old patient with uncontrolled diabetes and high blood pressure.
''How much?'' Dr. Michael E. Busha, a primary care physician at IU Health in Indianapolis, asked quietly as he updated Mr. Johnson's electronic record.
''Quite a bit.''
For Dr. Busha, that mattered.
He helps lead the IU system's effort to measure how well doctors do at keeping patients healthy. And even this champion of ''quality measures'' -- vital to the Obama administration's goal of paying doctors based on outcomes, not the amount of care -- has found that it is not always easy to meet them.
If enough of his patients fall below the standards set by IU Health, Dr. Busha could lose some of his income. The average salary for the system's primary care doctors is $236,000. Of that, $50,000 is tied to meeting benchmarks for quality, access (whether a doctor agrees to see patients on weekends and at night, for example) and other performance measures.
Mr. Johnson, who registers patients when they arrive for neurology appointments at IU Health Methodist Hospital in Indianapolis, was not helping. He also had stopped taking his cholesterol medicine because it left a bad taste in his mouth. And he was using neither the gym membership that IU Health helps pay for nor his sleep apnea machine. ''I never could get adjusted to it,'' he told the doctor.
Like other primary care doctors at IU Health, Dr. Busha is part of a team that includes a pharmacist, a social worker and a ''care manager.'' Such teams, encouraged by the health law, focus on patients like Mr. Johnson who are not meeting IU Health's quality measures, and who are disproportionately likely to end up in the emergency room or be hospitalized.
''The whole paradigm now is to identify your high-risk people and provide more resources to them, provide better care to them, keep them out of the hospital,'' said Dr. Kiray, the primary care co-chief.
Partly because of these efforts, IU Health's two adult hospitals in downtown Indianapolis are already seeing 12 percent fewer inpatients than they were in 2013. The system is merging the two hospitals into a $1 billion medical center focused heavily on outpatient care.
President Obama would be proud. Administration officials have continually emphasized the importance of primary care and the ''social determinants'' of health. They have offered grants to health care providers to identify Medicaid and Medicare patients with unmet social needs: inadequate food supplies, unpaid rent or utility bills and experience with violence at home, for example.
But with some patients, only so much can be done: Mr. Johnson's care manager had stopped working with him after deciding he was not ready to make changes.
''Are we ready to try it again?'' Dr. Busha asked him.
Mr. Johnson agreed to let the care manager contact him, and to return for a follow-up visit in two months.
Such efforts, said Mr. Murphy, the system's chief executive, will remain ''highly relevant'' even if the Affordable Care Act is repealed.
The push toward a ''risk-based'' model over traditional fee-for-service medicine has spread beyond Medicare and Medicaid to private insurers. And the Obama administration has been testing new ways to save money on all sorts of medical care. Some of the experiments, overseen by an office created under the Affordable Care Act, have shown promise. But evaluating results is difficult.
''It may be good in theory,'' Dr. John M. Thomas, a primary care physician at an IU Health practice in Lafayette, said of Dr. Busha's system of quality measurements. ''But there are a lot of flaws.''
For example, he explained, rather than risk being paid less because some patients have uncontrolled diabetes, doctors could tell those patients, ''I'm sorry, you're not in compliance with your medications, and I don't want to be your physician.''
Dr. Busha said he was used to hearing such arguments.
''I have that conversation on a weekly basis,'' he said. ''You know: 'What if my patients don't believe in immunizations? Why am I held accountable for that?'''
He added, ''We kind of tell them, 'It's your job to convince them.'''
Suddenly, Cost Counts
When IU Health discovered that a knee surgeon was using ''bone cement'' costing $300 a patient while another achieved the same results for $84, the first doctor was promptly informed. He switched.
IU Health now posts a color-coded ''value tracker'' in operating rooms that gives a green light to lower-cost surgical products, a red light to high-cost items and a yellow light to those in between.
''A huge cultural shift,'' Dr. Anthony T. Sorkin, the medical director of orthopedics, said of the changes in his department -- for the surgeons and the patients.
The IU Health system performed 3,900 hip- and knee-replacement operations in the year that ended on June 30. But it is not enough for doctors just to replace a knee or a hip. They are under pressure, from Medicare and private insurers, to manage and coordinate care for their patients before and after surgery. And, they say, payment for their services is continually being squeezed.
Doctors have three main ways to cut costs: improve the condition of patients before surgery, look for savings in every item used in the operating room (gloves, gowns, syringes, surgical tools, sutures, sponges and the implant itself), and send patients to nursing homes that strive to shorten the length of stay.
''I've been an orthopedic surgeon for 18 years,'' Dr. Sorkin said. ''For many of those years, I never once considered the cost for nursing homes.''
Why such attention to cost? In 67 geographic areas, including Indianapolis, Medicare now sets a target price for joint-replacement procedures. That target covers not only doctor services and hospital care but also 90 days of follow-up services like physical therapy, home health care and nursing-home stays. Hospitals are at risk: Medicare can pay bonuses or impose penalties, depending on whether spending targets and quality standards set by the government are met.
''We worry about 90 days of care, 90 days of Medicare spending, not just the brief time a patient spends in the hospital,'' Dr. Sorkin said.
The joint-replacement program was one of the main targets of the letter that Mr. Price and other Republicans wrote to the Obama administration in September, complaining that such programs should be tested on a ''voluntary, limited-scale basis'' with no requirement for doctors to participate.
But in Indianapolis, the results have been promising. By working closely with nursing homes, IU Health halved the length of stay for patients recuperating from surgery, to an average of 12 days from 24 days in early 2016.
Doctors and nurses understand the need for change, but some still have concerns.
''These reforms are all intended to slow down the consumption of health care resources in the United States,'' said Dr. Meneghini, who is the director of joint-replacement at Saxony Hospital here in Fishers. ''We are careening at a rapid rate to a two-tier system. The public who can't afford it goes to a public hospital and gets free health care. Those who have money get to pay for really nice care.''
A Mind Unchanged
Justin Kloski learned that he qualified for Medicaid under the worst of circumstances. The student and part-time lawn-company worker had lost 20 pounds, could not shake a nagging cough and was sleeping 14 hours a day when he decided to visit a clinic in Muncie, Ind., that provides free care for the poor and uninsured. A clinic employee invited Mr. Kloski, now 28, to apply for Medicaid.
A few days later, he took his new coverage to the emergency room at IU Health Ball Memorial Hospital in Muncie. A CT scan found a 15-centimeter tumor in his chest, so big it was pressing on his windpipe. In May 2015, he learned he had Hodgkin's lymphoma, a form of cancer that is curable if caught early.
The Affordable Care Act, and Governor Pence's decision to go against many other Republican governors and expand Medicaid under the law, may well have saved Mr. Kloski's life.
He is among more than 400,000 Indiana residents -- many of them previously uninsured -- who have enrolled in Medicaid since Mr. Pence expanded it in 2015, the 10th Republican governor to do so. Under the terms of the health law, anyone with income up to 138 percent of the poverty level, or approximately $16,500 a year for an individual, now qualifies in states that opt to expand the program.
IU Health says it receives more Medicaid payments than any other health care provider in the state. Since the expansion began, the percentage of patients with Medicaid has grown to 23.2 from 20.7.
At the same time, the percentage of IU Health patients who are uninsured has fallen to 2.2 from 5.
In 2015 alone, the health system enrolled 14,000 people in Medicaid or private coverage, sometimes even signing up patients as they lay in hospital beds.
''We went all in because it's a pretty big deal to us,'' said Jonathan W. Vanator, IU Health's vice president for revenue cycle services.
In the first nine months of last year, IU Health officials said, the amount of bad debt owed by patients and referred to collection agencies totaled $233 million, a 23 percent reduction from the comparable period in 2015, thanks largely to Mr. Obama's health law.
But, the officials added, these gains have been largely offset by cuts in Medicare reimbursements and other federal funds under a law that has given and taken away.
Mr. Murphy is among many hospital executives now anxious about the possibility of seeing a bump in uninsured patients if the health law is repealed, while not getting back the federal funds they gave up under the health law. ''I do think it would be problematic if part of the deal was changed and not the whole deal,'' he said.
Mr. Pence expanded Medicaid only after the Obama administration agreed to let Indiana do it in its own way: Instead of getting virtually free coverage, as Medicaid recipients in many other states do, people enrolled in Indiana's expansion pay up to 5 percent of their income toward it. Mr. Trump appears interested in promoting Indiana's ''personal responsibility'' model: He has picked its chief architect, Seema Verma, to run the Centers for Medicare and Medicaid Services.
Since Mr. Kloski had no income when he enrolled, he paid $1 a month; he has since been classified as ''medically frail'' and does not have to pay anything.
Medicaid has paid for virtually all of his cancer care, including a one-week hospitalization after the diagnosis, months of chemotherapy, and frequent scans and blood tests.
But Mr. Kloski and his mother, Renee Epperson, are still not fans of the health law over all. They believed that it required that Mr. Kloski be dropped, when he turned 26, from the health plan his mother has through her job at Target -- not understanding that it was the law that kept him on the plan until he was 26.
Mr. Kloski paid a penalty for going uninsured in 2014 rather than even explore whether he might qualify for a subsidy and find an affordable private plan through the marketplaces.
''There were so many horror stories about how expensive it was going to be,'' Ms. Epperson, 47, recalled. ''Justin said, 'I'm not even going to try it, Mom.'''
And until they were interviewed for this article, the mother and son did not know that the law was responsible for the expansion of Medicaid that Mr. Kloski benefited from. Neither voted in last year's presidential election; Ms. Epperson said that she disliked both candidates, and that even though Hillary Clinton supported the Affordable Care Act, she found Mrs. Clinton's positions unacceptable on too many other issues, like abortion rights, to support her.
Still, she said, she ardently hopes that Mr. Trump and the Republican Congress will continue allowing low-income adults like her son to qualify for Medicaid.
''Oh my God, yes,'' she said. ''Absolutely.''
As for Mr. Murphy, IU Health's chief executive, he said that while he did not want to think too much about changes that were still hypothetical, the prospect of losing the Medicaid expansion made him anxious.
''I worry about lots of things,'' he said. ''That list is probably 50 long, and this is definitely on that list.''
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URL: http://www.nytimes.com/2017/01/02/us/politics/obama-health-care-affordable-care-act.html
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GRAPHIC: PHOTOS: President Obama at the White House after signing the Affordable Care Act into law in March 2010. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES) (A12)
At right, Dr. R. Michael Meneghini, left, performing a partial knee replacement at a hospital in the Indiana University Health system. (A12-A13)
Lindsay Ehrgott is trained to help patients at IU Health Methodist Hospital sign up for health care if they are not already covered.
Justin Kloski, who has Hodgkin's lymphoma, showing the port on his chest for treatments. Medicaid has paid for virtually all of his cancer care. (PHOTOGRAPHS BY ILANA PANICH-LINSMAN FOR THE NEW YORK TIMES)
Protesters gathered in Washington in anticipation of a United States Supreme Court ruling on the health care overhaul law in June 2012. (PHOTOGRAPH BY BRENDAN HOFFMAN FOR THE NEW YORK TIMES) (A13)
DOCUMENT-TYPE: News; Series
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The New York Times
November 29, 2012 Thursday
Late Edition - Final
Health Care Entitlements
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 30
LENGTH: 713 words
Congressional Republicans are insisting that big cuts to Medicare and Medicaid be on the table in the negotiations over the so-called fiscal cliff and deficit reduction. That stance is largely a political move against two programs, which have been critical to the public welfare for the past half-century.
Postelection polls show that large majorities of voters for both President Obama and Mitt Romney opposed making large Medicare cuts as a way to reduce the budget deficit. And, the fact is, the Obama administration has already pledged to extract more than $1 trillion in savings over the next decade from these programs. There is not much more that can be cut without hurting the most vulnerable Americans.
The Affordable Care Act contains provisions that will reduce projected Medicare spending by $716 billion over 10 years, primarily by reducing the annual increases in Medicare reimbursements for hospitals, nursing homes and other health care providers and by reducing unjustified subsidies paid to private Medicare Advantage plans. During the campaign, the Romney-Ryan ticket criticized the president for making such a big cut and even fatuously promised to restore all of it.
On top of those savings, President Obama, in his budget for fiscal year 2013, proposed cutting another $340 billion from Medicare spending over 10 years through tactics like requiring drugmakers to pay rebates to Medicare in some circumstances; reducing payments to some health care providers for treating patients just released from the hospital; reducing coverage of bad debts that hospitals and skilled nursing homes have failed to collect from patients; and charging higher premiums to high-income beneficiaries.
Those cuts seem acceptable as part of a larger budget deal to avert the fiscal cliff. There may be room to squeeze additional savings from health care providers as long as their fiscal health is not jeopardized. But, beyond that, there are very limited options for further reducing Medicare or Medicaid spending.
Upper-income beneficiaries already pay higher Medicare premiums, and there may be some room to charge them more. But middle-income beneficiaries need to be protected from higher costs. And the half of all Medicare beneficiaries who have incomes below $20,000 already pay sizable portions of their income for health care and certainly cannot afford to pay more.
Some ideas should be off the table entirely. The election made it clear that there is strong opposition to turning Medicare into a voucher system. And, as for raising the Medicare eligibility age, respected analysts have concluded that this change would actually increase total health care costs and shift the burden to employers and individuals, without saving the government much money.
Finally, it's important to keep in mind that short-term cuts in Medicare are not urgently needed. Medicare spending per enrollee is projected to increase more slowly than per capita gross domestic product or private insurance spending per enrollee over the next decade, and it is only in the following years that strong cost controls may have to come into play as the population ages and medical costs continue to rise.
Medicaid, a joint state-federal program of health insurance for the poor, has even less ability to absorb cuts. Although Mr. Obama proposed last year to cut federal spending on Medicaid by about $100 billion over 10 years, he soon trimmed that amount to $55 billion in his 2013 budget. Since then, the picture has changed drastically.
Although the Affordable Care Act required the states to expand their Medicaid programs to cover millions of the uninsured, the Supreme Court said the states could decide voluntarily whether to expand. Those that refuse to expand will save the federal government a lot of money in matching funds. The administration should not make any further cuts lest it discourage states from expanding coverage, unless the savings are achieved through better health care management.
The best way to rein in the Medicare and Medicaid costs is to speed up and extend provisions in the Affordable Care Act to encourage better and more efficient ways to deliver health care. That would help reduce federal deficits in the future and save substantial money for the private sector as well.
URL: http://www.nytimes.com/2012/11/29/opinion/health-care-entitlements.html
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(Economix)
August 31, 2012 Friday
From Physician Glut to Physician Shortage
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1146 words
HIGHLIGHT: Concerns about a doctor shortage — a questionable premise — might best be harnessed into seeking new efficiencies in how medicine is practiced, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
In my most recent post, I made light of the argument that the Affordable Care Act would lead to a major shortage of physicians in this country. I was unpersuaded in part because the newly insured are likely to present only a marginal added demand for physician services. More important, I am not sure what we mean by "physician shortage."
Forecasters looking at the health work force have never reached a consensus on the ideal physician-population ratio for this country.
Indeed, widespread worries over a looming physician shortage are a relatively new phenomenon. They come at the time when experts are also lamenting an "epidemic of overtreatment" of patients, said to cost America $210 billion a year.
Throughout the 1980s, however, and until the late 1990s, the dominant narrative among experts on the American health work force was that, with the exception of primary care physicians, the United States faced a large overall future physician surplus. There were only a fewdemurrals from that dominant narrative.
The problem is that forecasting the future supply of and demand for any type of health professional is a highly complex and nuanced enterprise with wide margins of error (see, for example, Figures 9-1 and 9-6 in my 1991 paper).
Crucial in such forecasts is the assumption one makes about the average annual physician productivity in future years. That variable depends chiefly on two factors: the number of hours per year that physicians typically devote to patient care, and the degree to which physicians delegate to others tasks for which an M.D. degree is not required - for example, administrative tasks to clerks or business managers and certain medical tasks to physician assistants or nurse practitioners trained to perform tasks now performed by physicians.
How crucial that assumption is can be inferred from a once highly influential paper written in 1994 by Jonathan Weiner, a Johns Hopkins University health services researcher. In that study, Professor Weiner sought to estimate the impact of the then-impending Clinton health reform on the country's future work force situation.
Professor Weiner noted that, in 1992, well-managed, clinically integrated, staff- or group-model health maintenance organizations that were compensated by prepaid capitation (an annual lump-sum fee per patient) required an average of only about 120 or so physicians per 100,000 enrollees, while the overall ratio of patient-care physician per 100,000 population in the United States was as high as 180 (about 220 in 2011; see Table 2 in this publication).
It appeared that the H.M.O. had pushed task delegation to nonphysician personnel further than had the rest of the health system. Furthermore, H.M.O.'s freed clinicians substantially from many administrative chores that physicians elsewhere must perform. Such H.M.O.'s, incidentally, would be the ideal form of the accountable care organizations called for in the Affordable Care Act of 2010.
Assuming, when he made the forecast in 1994, that as a result of the Clinton health reform some 40 to 60 percent of the United States population would be enrolled in such H.M.O.'s by 2000, Professor Weiner projected that the demand for and supply of primary care physicians would be more or less in balance in 2000, but that the supply of specialists would exceed the demand for them by more than 60 percent (a projected surplus of 165,000 physicians).
This prospect - widely accepted at the time - subsequently led the prestigious Council of Graduate Medical Education to recommend in its report of 1996 that "that the number of physicians entering residency be reduced from 140 percent to 110 percent of the number of graduates of allopathic and osteopathic medical schools in the United States in 1993."
And why were health policy makers and work force specialists so worried at the time about an impending physician surplus? Did not standard economic theory predict that an imminent surplus would drastically drive down physician fees - particularly specialists' fees - and thus make health care more affordable and accessible?
The problem is that this theory has found little empirical support in the data, in part because third-party payment intervenes. Furthermore, there has always been a strong belief, especially among policy makers, that modern medical practice, when coupled with third-party payment, is subject to an analogue of Parkinson's Law. It is named after the British historian Cyril Northcote Parkinson (1909-93), who promulgated the law more or less in jest in 1955, then with regard to the British civil service.
According to Parkinson's Law, "work will expand to fill the time available for its completion." In medicine, its manifestation is feared to be the overtreatment of patients - sometimes harmful - even though individual physicians may sincerely believe that more care implies superior quality of treatment.
As the late economist Eli Ginzberg, an early pioneer in work force studies, noted as early as 1966: "Physicians are in a position to create their own demand." He added that the effective use of physician manpower "depends in the first instance on a taut supply of physicians."
Academic economists since that time have tied themselves into analytic knots over whether or not Ginzberg was right, in exercises reminiscent of medieval scholasticism. At the theoretical level, their models are mathematically elegant but lack predictive power. The data available at the empirical level does not allow economists to distinguish between health care actively demanded by patients and health care passively accepted on the doctor's recommendation, nor between services prescribed by doctors in good conscience and those rendered mainly to shore up doctors' incomes.
As on so many other areas of the real world, the views of economists on this matter cancel one another out.
Policy makers in the real world, however, seem to have no doubt that Parkinson's Law applies to medical practice, as well. Consequently, they prefer paying physicians by annual capitation or bundled payments instead of "inflationary" fee-for-service, and they often seek to impose global budgets on physicians.
If Eli Ginzberg was right - and often he was - the suspected physician shortage now imputed by critics of the Affordable Care Act may actually drive our health system into more efficient medical practice. Step No. 1 in that direction, of course, would be to lighten the enormous administrative load now heaped by our health insurance system onto physicians devoted to rendering patient care.
Health Reform, the Reward to Work and Massachusetts
Older Workers Could Benefit if Companies Drop Insurance
The Incomes of Physicians
Shocked, Shocked, Over Hospital Bills
In Massachusetts We Trust
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The New York Times
September 9, 2011 Friday
Late Edition - Final
Federal Panel Dismisses Health Law Challenges
BYLINE: By KEVIN SACK
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 669 words
A federal appellate court in Richmond, Va., on Thursday threw out a pair of cases challenging the constitutionality of President Obama's 2010 health care law, ruling for varying reasons that the plaintiffs did not have legal standing to sue.
In the process, however, two of the three judges on the panel volunteered that they would have upheld the law, known as the Affordable Care Act, if they had been able to rule on the substance of the cases.
The rulings, by the Court of Appeals for the Fourth Circuit, vacated lower court decisions -- one for and one against the law.
In late June, a three-judge panel of the Court of Appeals for the Sixth Circuit in Cincinnati ruled 2-to-1 in favor of the law's requirement that, starting in 2014, most Americans must obtain health insurance. In August, the Court of Appeals for the 11th Circuit in Atlanta ruled against that provision, known as the individual mandate, also by 2-to-1.
Still other cases continue to progress through the appellate process. The Supreme Court has yet to signal whether it will accept one or more of the cases.
The Fourth Circuit confronted two opposing lower-court decisions. One, in a case filed by Virginia's attorney general, Kenneth T. Cuccinelli II, had overturned the law's insurance requirement. The other, in a case filed by Liberty University, a Christian college in Lynchburg, Va., upheld the same provision, which is considered central to the act.
In a unanimous opinion written by Judge Diana Gribbon Motz, the Fourth Circuit panel concluded that Mr. Cuccinelli did not have standing to sue because Virginia's case relied on a state law intended to undermine the federal act. Unlike in the Liberty case, which included individual plaintiffs who might someday be directly affected by the mandate, Mr. Cuccinelli structured his complaint as a conflict between state and federal law.
The Virginia Health Care Freedom Act, enacted one day after Mr. Obama signed the Affordable Care Act, declares that no Virginia resident ''shall be required to obtain or maintain a policy of individual insurance coverage.''
But Judge Motz wrote that states cannot grant themselves standing to challenge federal laws simply by passing legislation that declares those laws invalid. A state, she wrote, does not ''acquire some special stake in the relationship between its citizens and the federal government merely by memorializing its litigation position in a statute.'' Mr. Cuccinelli said Thursday that he would appeal to the Supreme Court.
In the Liberty case, Judge Motz wrote for a 2-to-1 majority in rejecting the appeal on entirely different grounds. In that case, she wrote that Liberty could not seek to strike down the individual mandate before it took effect because doing so would, in effect, usurp the government's right to collect a tax.
That, she said, would run afoul of the long-established federal Anti-Injunction Act, which bars litigation seeking to restrain the assessment or collection of a tax.
The question of whether the law's penalties constitute a tax has been considered in a number of the court challenges because the Constitution grants Congress broad authority to levy taxes to support the nation's general welfare. On Thursday, the Fourth Circuit panel ruled that while the health care act refers frequently to penalties, the fines for noncompliance are in fact taxes.
The dismissal of the appeal on the tax question blocked the panel from fully considering the constitutionality of the individual mandate. But Judge Motz's colleagues offered personal opinions.
Judge James A. Wynn Jr. wrote in a concurring opinion that he would have upheld the act based on Congress's authority under its taxing powers. Judge Andre M. Davis, who dissented from the conclusion that the federal courts did not have jurisdiction, wrote that he would have upheld the mandate under Congress's power to regulate interstate commerce.
All three randomly selected judges on the panel were appointed by Democratic presidents, including two by Mr. Obama himself.
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(Taking Note)
August 17, 2012 Friday
For Selfish Seniors Only
BYLINE: DAVID FIRESTONE
SECTION: OPINION
LENGTH: 449 words
HIGHLIGHT: A new ad says the president raided Medicare to fund his 'massive new government program.'
Among the many falsehoods in the Romney campaign's new Medicare ad is this remarkable line pitched to the elderly: "The money you paid in for guaranteed health care is going into a massive new government program that's not for you."
Those three words "not for you," encapsulate the Republican Party's approach to that "massive" program, the Affordable Care Act, as a wedge issue. It's not enough to say that President Obama took $716 billion out of Medicare, because Paul Ryan's budget did the same thing. The point is that those billions are being spent on the wrong people, those unnamed others who inevitably lurk just outside of Republican ads.
The implication is that Obamacare is for the poor, the uninsured, blacks, Hispanics, immigrants, anyone but the upstanding older Americans that the Romney-Ryan ticket is suddenly very afraid of losing. "It's not for you."
As it happens, the ad is incorrect. For instance, the president's health care bill eliminated the notorious Medicare "doughnut hole," which forced beneficiaries to use their own money for prescription drugs after they reached a limit. That hole, created by President George W. Bush and Congress, had a serious health effect on millions of older Americans. Many studies showed that it forced people to stop taking their medications or to skip doses.
Getting rid of the gap is one of the best things about health care reform, and it doesn't just affect those "other people." That's why you never hear Mitt Romney or Mr. Ryan talking about it when they promise on the stump to repeal Obamacare on their first day in office.
The real purpose of the health care reform is to reduce the number of Americans without insurance. This change will improve public health and decrease the financial burdens on hospitals. Keeping people healthier as they age into Medicare will help keep the program solvent for all.
The ad seems to assume that older Americans don't care about any of that, that they are selfishly focused only on their own immediate benefits and don't care about upcoming generations, including their own children and grandchildren. It assumes they feel about 30 million uninsured people the way Senator Mitch McConnell does: "That is not the issue."
That's not terribly surprising from a campaign that wants to end all federal responsibility for Medicaid and food stamps - entirely for "other people" - and is running another deceitful ad that accuses the president of freeing welfare recipients from work requirements. The message seems to be that if you care about these things, the Romney campaign is not for you.
Evil Bain and the Evil Empire
Health Care Confusion
Return of the Swift Boat
Medicare Confusion
Forcing Flip-Flops
LOAD-DATE: August 17, 2012
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The New York Times Blogs
(The Caucus)
March 26, 2012 Monday
Poll: 47% Disapprove of Health Care Law
BYLINE: DALIA SUSSMAN
SECTION: US; politics
LENGTH: 372 words
HIGHLIGHT: The sweeping federal legislation has never gained the support of most Americans in New York Times/CBS News polls.
More Americans continue to disapprove of the federal health care legislation than support it, with a deep partisan divide underscoring their views, according to a New York Times/CBS News poll.
Passed in 2010, the Affordable Care Act has never won the support of most Americans in surveys by The Times and CBS News, highlighting the Obama administration's lack of success in winning over the general public to its signature domestic accomplishment.
Republicans have maintained a steady drumbeat against the law on Capitol Hill and on the campaign trail. Some of the legislation's most contentious provisions will be under scrutiny this week at the Supreme Court where 26 states are challenging the law's constitutionality in three days of arguments.
The new poll, conducted last Wednesday through Sunday, finds that 36 percent of Americans approve of the health care law, while 47 percent are opposed. By nearly 2 to 1, those who say they strongly disapprove of the law outnumber those who strongly approve of the legislation. Sixteen percent have no opinion.
Views reflect the respondents' partisanship. A majority of Democrats in the poll approve of the law, though not overwhelmingly so - 56 percent approve, including 28 percent who strongly approve. Approval peaks among self-described liberals, at nearly two-thirds.
But intensity of sentiment is much stronger on the other side of the political divide, with most Republicans not only opposed to the law's provisions, but strongly so.
About three-quarters of Republicans disapprove, with more than 6 in 10 expressing strong disapproval, according to the survey. Results are similar among respondents who support the Tea Party movement. Disapproval peaks among people who call themselves very conservative, with more than 8 in 10 opposing the law.
More independents agree with Republicans about the law than with Democrats, with 51 percent of these important swing voters saying they disapprove of it.
The nationwide poll is based on telephone interviews conducted March 21-25 on landlines and cellphones with 986 adults and has a margin of sampling error of plus or minus three percentage points.
Additional results from this poll will be available Monday evening at NYTimes.com.
LOAD-DATE: March 27, 2012
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The New York Times
April 18, 2014 Friday
Late Edition - Final
Signups Exceed Obama's Goal for Health Act
BYLINE: By MARK LANDLER and MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1165 words
WASHINGTON -- President Obama announced Thursday that eight million people have signed up for health insurance under the Affordable Care Act, including what the White House said were a sufficient number of young, healthy adults, a critical milestone that might counter election-year attacks by Republicans on the law's success and viability.
The total number of enrollees exceeds by a million the target set by the administration for people to buy insurance through government-run health care exchanges. In particular, the number of young people signing up appears to have surged during the final weeks of enrollment.
''This thing is working,'' Mr. Obama told reporters in the White House briefing room, in what amounted to a second victory lap after he announced two weeks ago that 7.1 million people had signed up for insurance during an initial enrollment period. ''The Affordable Care Act is covering more people at less cost than most people would have predicted a few months ago.''
Still, critics of the law cautioned that promising top-line numbers were not by themselves proof of success.
Although more young people signed up for health insurance, for example, the number remained below the level that some analysts believe is optimal for keeping premiums low in the insurance marketplaces. The administration said Thursday that 28 percent of those who bought policies were between the ages of 18 and 34, but some analysts said the optimum level would be 40 percent.
''In an ideal world, you'd want to get as close to that as possible,'' said Larry Levitt, a senior vice president at the Kaiser Family Foundation. ''But what is important is what the insurance companies expected, and this is what they expected.''
The administration did not release two other crucial statistics that would help determine the success of the law: the number of people among the eight million who bought insurance for the first time and the number who paid their initial premiums.
The number of those who were previously uninsured is important, since many people could simply have been moved from plans that were canceled by the law. Administration officials have promised to release that information when they have it, but they have said it is not data that is collected by the government.
Administration officials have said previously that they could not tell how many people have paid premiums because those payments are between individuals and their insurance companies. In February, however, industry experts and insurance companies said that one in five people who signed up failed to pay their premiums on time and therefore did not receive coverage when it began in January.
Mr. Obama nonetheless seized on the numbers to make his case that the law is a success and to challenge his opponents to drop their opposition to it. ''I find it strange that the Republican position on this law is still stuck,'' the president said. ''They still can't bring themselves to admit that the Affordable Care Act is working.''
Mr. Obama's remarks came a week after he announced the resignation of Kathleen Sebelius, his health and human services secretary, at an orchestrated White House event that sought to put a positive light on a tenure marred by the disastrous rollout of the HealthCare.gov website that Ms. Sebelius oversaw last year. On Thursday, Mr. Obama focused his remarks on the future.
''We've got a sizable part of the U.S. population, for the first time, that are in a position to enjoy the financial security of health insurance,'' the president said.
Mr. Obama spoke after meeting with state insurance commissioners at the White House, where he shared some of the new enrollment numbers and demographic data.
In the early months of signups, the number of young people between the ages of 18 and 34 -- who tend to be healthier -- hovered around 25 percent. But as White House officials predicted, many young people appear to have waited until close to the March 31 deadline to enroll, increasing their participation. The administration had offered a grace period until Tuesday to accommodate people who had begun, but not completed, the signup process by a deadline of March 31.
Health experts have long warned that the state-by-state, competitive insurance marketplaces set up by the law could be severely undermined if the pool of customers who signed up were mostly sick or elderly. In such a case, premiums could spike, and insurance companies might choose to abandon the federal marketplaces entirely.
The overall percentage of young people enrolled is not a guarantee that all of the insurance marketplaces across the country will work perfectly. Individual insurance companies will make decisions about what their premiums are based on the makeup of their own client list.
But the higher proportion of young enrollees is a rebuke to the critics of the Affordable Care Act, who had predicted that it would fail to attract younger, healthier customers to buy insurance.
In the months ahead, insurance companies will assess the age and health of their customers as a way of determining their premiums for next year. Mr. Obama said he expected premiums would probably increase, as they have annually for many years.
But White House officials insisted that the overall cost of health care is rising more slowly than previous estimates by the Congressional Budget Office. And they said that the higher proportion of young people who have enrolled is likely to keep many premiums lower than they would otherwise have been.
''Health care spending has risen more slowly than at any time in the last 40 years,'' Mr. Obama said.
In recent weeks, as the enrollment numbers improved from the difficult start last fall, Mr. Obama and his aides have become more aggressive in their efforts to promote moments in the law's success.
By having Mr. Obama be the first person in the administration to announce the latest enrollment numbers -- in previous months, that task often went to Ms. Sebelius -- administration officials signaled their willingness to more directly engage Republican critics on a by-the-numbers assessment of the law.
In addition to the enrollment figures, officials on Thursday cited other statistics that they said proved the law was working. They said 129 million Americans with pre-existing health conditions, including 17 million children, were no longer in danger of losing health coverage or having premiums rise drastically.
They also said that 105 million people did not have to worry about reaching a lifetime cap on insurance benefits, something that was made illegal under the health law. And they said that eight million older Americans have saved $10 billion because of lower prescription drug costs under the law.
Republicans dismissed the president's announcements, saying they were a misleading attempt to make the health law look rosier than it is. Brendan Buck, a spokesman for House Speaker John A. Boehner, said the White House was continuing to ''obscure the full impact of Obamacare.''
URL: http://www.nytimes.com/2014/04/18/us/obama-says-young-adults-push-health-care-enrollment-above-targets.html
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March 14, 2014 Friday
The I.R.S.'s Final Mandate Reporting Rules? Still Complicated
SECTION: BUSINESS; smallbusiness
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HIGHLIGHT: The final regulations have been released, and business groups are complaining that the only streamlining the I.R.S. appears to have achieved is for itself.
Last summer, the Obama administration delayed implementing the employer mandate in the Affordable Care Act because, it said, it needed time to figure out how it might simplify the law's complicated reporting requirements for businesses with 50 or more employees. "We don't necessarily need to load up the vast majority of companies that are already doing the right thing with a bunch of additional paperwork," President Obama told The Times in an interview in July, asking, "Are there simpler ways for us to allow them to certify that they're providing health insurance?"
But the final regulations were released last week, and business groups are complaining that the only streamlining the Internal Revenue Service appears to have achieved is for itself.
"A lot of the provisions here for precertification and managing reporting requirements, particularly for very large employers, are really not very helpful," said Neil Trautwein, employee benefits policy counsel at the National Retail Federation. "And I think it's really cast more to meet the needs of the cash-strapped I.R.S. and their clunky computer systems."
The regulations at issue implement two new sections of the tax code created by the Affordable Care Act. Section 6056 helps the I.R.S. enforce the mandate on so-called "applicable large employers" - those with 50 or more employees - to provide full-time workers with health insurance that meets the law's standards for quality and affordability. It will also help the agency determine whether employees who use tax credits to buy their own insurance on the new state exchanges are entitled to a subsidy. A company pays a penalty when a full-time employee buys individual insurance with a subsidy.
Another new section of the code, Section 6055, is meant to help the I.R.S. make sure that individuals comply with their new obligation to have insurance. Under Section 6055, insurance providers are required to share the names of individuals enrolled in health plans throughout the year with the I.R.S. and also provide the same information to each household. Companies that self-fund their insurance plans also bear this burden of notification.
Some business groups said that collecting the Social Security numbers of an employee's dependents, as the rules require, raised privacy concerns. "We have never collected dependent Social Security numbers, and we think there are other ways they could do it," said Michelle Neblett, director for labor and work-force policy at the National Restaurant Association. "But because of the way the I.R.S. system is set up, they say they need tax ID numbers."
The bulk of employer reservations involve Section 6056. For each full-time employee, the law specifies that a company subject to the mandate must report, among many other details, whether the employee was offered insurance for each month of the year, the cost to the employee of the least expensive insurance option in each month, and the months in which the employee was covered by insurance. The law requires monthly reporting because the company must offer insurance in each month of the year in order to avoid the penalty and because the tax credits are available to individuals on a month-by-month basis.
In its final rule, the I.R.S. created an exception to the reporting requirements for companies that offer compliant insurance policies that are so inexpensive that no employee could find them unaffordable under the law. The Affordable Care Act deems health insurance unaffordable when the worker's share of the premium cost exceeds 9.5 percent of his or her household income. The reporting regulations set the ceiling for the employee's cost of a universally affordable health plan at 9.5 percent of the federal poverty level.
For employees who work the full year, the employer can indicate in a single box that the employee received an offer of coverage. For other employees, the company would use codes to show whether an employee was offered coverage in each month. In either case, the employer would not have to report the cost of coverage. The agency also decided to combine the separate forms required by the new sections into a single document so companies would not have to file two forms for each employee.
Business groups said this effort at streamlining would help few companies. "It's hard to qualify for the en masse reporting," Mr. Trautwein said. "From what my members are telling me, just figuring out who can be included in that report, who can't be included in that report, is a headache."
Ms. Neblett, of the restaurant association, said that her member businesses could not sustain offering insurance so cheaply to workers. In 2015, a qualifying plan can cost an employee no more than $92 a month. "The employer is going to be paying a very high percentage of the premium each month," she said, "which in our business, that operates on thin margins, is a concern."
An official at the Treasury Department, who insisted on anonymity, said that an earlier rule making it easier for employers to comply with the mandate left the agency with less flexibility for the reporting requirements. The original rule gave employers a shortcut to determining whether the insurance they offered was affordable; instead of basing it on a worker's household income, which an employer is unlikely to know, an employer can set the offer at 9.5 percent of the employee's wages. If it turns out that the offer exceeds 9.5 percent of household income - because, say, the employee pays alimony - the worker can turn down the offer, but the company is off the hook for the penalty.
"That was a very beloved rule that we were very careful to provide," the official said. But, the official added, "a lot of people have household income smaller than their wages," and they are entitled to buy insurance subsidized with a monthly tax credit. "We were trying to figure out what's the least amount of reporting that's necessary under the statute in order for the statute to work reasonably for individuals, employers, and the tax system," the official said.
"I think they did the best they absolutely could given the confines they were working under," said Seth Perretta, an attorney from the Washington firm Crowell & Moring, who has represented several trade groups in the rule making. "When you realize you need all the individual data elements in order to enforce the individual mandate and the employer mandate, then there isn't a lot of flexibility you can give in terms of content."
The I.R.S. had floated several proposals that would allow companies to avoid reporting on individual employees, or to avoid collecting monthly data. One idea under consideration would have allowed a company to certify that it offered all of its employees affordable health insurance. If some employees wound up buying subsidized individual insurance, then the I.R.S. could notify the company, which would file detailed information returns only for those employees.
In the end, however, the agency concluded that none of the alternatives were workable. "From the I.R.S.'s perspective, they need to worry about the exceptions," said Pete Isberg, president of the National Payroll and Reporting Consortium, a trade group for payroll processing companies. In the case of a general certification, for instance, "you still have one, 2, 3, or 4 percent of employees who just didn't fit that for four months, and that's what the I.R.S. had to administer. And for four million workers, that's just not feasible."
Mr. Isberg said that had the business lobby gotten its way, companies, too, would soon sour on this sort of retrospective reporting. "They're going to have to go back to their time-keeping records from two years ago," he said, "and if you aren't keeping track of it in the first place, that's probably going to be a whole lot harder to do."
Study Indicates That Bill Redefining Full-Time Employment Would Have Costs
Assessing Who Benefits From the Latest Rulings on the Employer Mandate
Small Businesses Showing Little Interest in State SHOP Exchanges
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December 7, 2016 Wednesday
Late Edition - Final
Health Insurers List Demands if Affordable Care Act Is Killed
BYLINE: By REED ABELSON
SECTION: Section A; Column 0; National Desk; Pg. 22
LENGTH: 1176 words
The nation's health insurers, resigned to the idea that Republicans will repeal the Affordable Care Act, on Tuesday publicly outlined for the first time what the industry wants to stay in the state marketplaces, which have provided millions of Americans with insurance under the law.
The insurers, some which have already started leaving the marketplaces because they are losing money, say they need a clear commitment from the Trump administration and congressional leaders that the government will continue offsetting some costs for low-income people. They also want to keep in place rules that encourage young and healthy people to sign up, which the insurers say are crucial to a stable market for individual buyers.
The demands are a sort of warning shot to Republicans. While the party is eager to repeal the law as quickly as possible, and many have promised a replacement, its members are sharply divided over what shape any new plan should take. If they do not come up with an alternative, more than 22 million people would be left uninsured, including the more than 10 million who have bought individual plans on state marketplaces.
On Tuesday, Marilyn Tavenner, the chief executive of America's Health Insurance Plans, a leading industry trade group, warned that the state marketplaces were already on unstable financial footing. Failing to continue the funding aimed at low-income Americans, she said, would have far-reaching consequences because the business would become much tougher for insurers.
''The market has already been a little wobbly this year,'' Ms. Tavenner said. ''If insurance companies believe cost-sharing subsidies will not continue, they are going to pull out of the market during the next logical opportunity.''
Insurers could decide within a few months whether to pull out of the state marketplaces for 2018, a deadline they are pushing to have delayed.
The trade group, one of two major groups representing insurers, was a major force in the passage of the law in 2010 and is expected to be influential in its discussions with Republicans. While its clout has been reduced by the departure of large members like the UnitedHealth Group, the organization has a powerful voice in Congress.
The Blue Cross Blue Shield Association, the other major trade group, has not yet said what it needs from Republican lawmakers to continue operating in the market.
Ms. Tavenner, a former Medicare official in charge of overseeing the creation of the state marketplaces, brings deep knowledge of both the government's and the industry's roles in health care. She said her group had begun meeting with members of Congress and their staffs.
Hospital groups also held a news conference on Tuesday to warn of what they said would be the dire financial consequences of a repeal if the cuts to hospital funding that were part of the Affordable Care Act were not also restored.
While insurers say they do not plan to fight the Republicans' efforts to repeal the law, they are in no hurry to see it unwound. And Ms. Tavenner said the industry would support a delay so it could prepare for the changes. ''We would love to see a three-year time frame, as long as possible,'' she said.
The marketplaces, now three years old, have not become as robust as expected by many of the people behind the Affordable Care Act. Even President Obama, who pushed the law and the marketplaces through Congress, has suggested some improvements.
Some of the largest insurers, like UnitedHealth and Aetna, have stopped selling policies on some of the state marketplaces after losing hundreds of millions of dollars, and other insurers say they are still debating whether to stay in the market. Many have raised their premiums sharply.
Ms. Tavenner acknowledged that the current law ''needed to be improved.'' But she emphasized that there was widespread agreement among Republicans about the need for some the law's provisions, including covering people with expensive medical conditions. President-elect Donald J. Trump has also signaled his support of this popular provision. ''There are common starting platforms,'' she said.
Ms. Tavenner did not give many details about her group's positions, but she said its top priority was to stop the immediate threat of eliminating the subsidies for plans sold to low-income people. House Republicans have already sued to block these payments, and the lawsuit is now delayed. If the new administration chose not to defend the lawsuit, the money would disappear, and insurers would probably rush to the exits because fewer potential customers would be available.
Another of the industry's concerns is ensuring that enough young and healthy people sign up to stabilize the market. Republicans have discussed eliminating one of the law's main tools, the so-called individual mandate, a tax levied on those who do not enroll.
In talking with Congress, Ms. Tavenner said, her members are emphasizing the need for some alternative, especially after criticism by insurers that the penalty is not large enough to persuade enough people to enroll. ''There's not one magic solution,'' she said. She pointed to some of the provisions in Medicare that encourage people to sign up before they become sick. And she discussed some options to ease how insurers price their policies to be able to offer plans that are less expensive to younger people.
She also argued that the insurers had no desire to return to the time before the law was passed, when people with pre-existing conditions were routinely denied coverage in the individual market.
Still, the industry seems willing to embrace some of the ideas being discussed by Republicans, including giving individuals more choices of plans and more accountability for the cost of their health care. Republicans also seem eager to put the states in charge of some of the details of how coverage in both the individual market and Medicaid will look. Ms. Tavenner said the industry had a long history of working with state insurance regulators.
Republicans are discussing other ways to stabilize the market, including the creation of high-risk pools, where people with expensive medical conditions might be covered, bringing down the coverage costs for everyone else. ''We would hesitate to rush back to that,'' Ms. Tavenner said. In the past, those programs, typically run by the states, have not been adequately funded, she noted.
The insurers are also beginning to discuss a potential overhaul of Medicare, pushed by the House speaker, Paul D. Ryan, who favors so-called premium support, or vouchers, as a way for people to find coverage. ''We're not big fans of that approach,'' said Ms. Tavenner, although she said the industry would be open to discussing it.
Ms. Tavenner said the industry wanted to know more about what the Republicans were planning, including information on the fate of the Medicaid expansion under the law. ''We still have more questions than answers,'' she said. ''We don't want to disrupt individuals who are relying on our coverage,'' she said.
URL: http://www.nytimes.com/2016/12/06/business/health-insurers-obamacare-republicans.html
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October 23, 2013 Wednesday
Late Edition - Final
Judge Allows Challenge Of Law to Continue
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; IN PRACTICE; Pg. 20
LENGTH: 439 words
WASHINGTON -- A federal judge cleared the way on Tuesday for consumers to challenge President Obama's health care law on the grounds that the federal government cannot legally provide subsidies to people who buy insurance through the exchange run by it.
The judge, Paul L. Friedman, of Federal District Court here, said that four individuals could pursue their lawsuit challenging the Obama administration's interpretation of a provision of the law that defines who is eligible for subsidies.
The plaintiffs maintain that such subsidies -- tax credits to help defray the cost of health insurance -- are available only in states that establish their own exchanges, not in the 36 states where the exchanges are operated by the federal government.
The plaintiffs are from states using the federal exchange: Tennessee, Texas, Virginia and West Virginia. The subsidies make insurance more affordable for them. Without the subsidies, they say, insurance would be unaffordable, and they would be exempt from the requirement to carry insurance.
Opinions polls show that the requirement, often called an individual mandate, is one of the less popular provisions of the 2010 law, the Affordable Care Act.
A rule issued last year by the Internal Revenue Service says that tax credits are available to low- and middle-income people in every state, regardless of who operates the exchange.
Michael A. Carvin, a lawyer for the plaintiffs, said the rule flew in the face of the law written by Congress. He pointed to a section of the law that allows subsidies for people who enroll in health plans ''through an exchange established by the state.''
Under the law, people who go without insurance next year may be subject to tax penalties. Judge Friedman rejected the Obama administration's argument that he should dismiss the lawsuit and require the plaintiffs to pay the tax penalty and seek refunds.
''This is a final agency rule,'' Judge Friedman said. ''It's beginning to affect people now.''
One of the plaintiffs, David Klemencic, was involved in a separate case in which the Supreme Court last year upheld the health care overhaul law, including its requirement for most Americans to have insurance.
Reached at his retail carpet store in Ellenboro, W.Va., Mr. Klemencic said he was pleased that Judge Friedman had allowed his lawsuit to continue.
''I don't feel I need health insurance,'' Mr. Klemencic said. ''I pay my own health care bills and always have. I do not want to be forced onto some sort of welfare program, with the government paying for health coverage for me.''
This is a more complete version of the story than the one that appeared in print.
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March 11, 2017 Saturday
Late Edition - Final
Republican Health Bill Targets Abortion Coverage
BYLINE: By KATE ZERNIKE
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 778 words
The Republican proposal to replace the Affordable Care Act would bar people from using federal tax credits to buy health insurance plans that cover abortion.
If the measure is passed, abortion rights advocates fear it could compel insurers to stop offering abortion coverage at all.
''There's no reason insurers would sell any plans that cover abortion because everyone would be wanting to use these tax credits,'' said Adam Sonfield, a senior policy manager for the Guttmacher Institute, a research center that works to promote access to abortion.
For now, the proposal would create a big problem for two of the largest and most liberal states: California, where state law requires insurers to cover abortion, and New York, which has long encouraged coverage by including it in its model plan of what insurers have to cover. Massachusetts, too, has long indicated that insurers should cover abortion as ''medically necessary.''
The law, if passed, would all but make it impossible for Californians to use the new tax credits to buy health insurance.
''States would be faced with this choice: Do we get rid of our abortion coverage requirement, or deny state residents all the tax credits?'' said Gretchen Borchelt, the vice president for reproductive rights and health at the National Women's Law Center. ''It's putting states in a really terrible position.''
She and other advocates for abortion rights said they expected legal challenges from California and other states if the law passed. They argued it goes against Republican promises of increased options in health insurance, and their embrace of states' rights.
The proposal continues a move away from abortion coverage in recent years. Until the Affordable Care Act was passed in 2010, insurers in most states offered plans covering abortion. The A.C.A. allowed states to bar insurers from offering plans through the A.C.A. marketplaces that cover abortion and 25 states did so (except for coverage of abortions in cases of rape or incest, or where the woman's life is in danger). Ten of those extended that ban to prevent insurers from providing abortion coverage in any private insurance plan in the state.
Since 1977, the federal Hyde Amendment has prohibited federal money from going to abortions. Under the Affordable Care Act, state officials had to separate out the federal subsidies used to buy health insurance into separate funds so that no federal money would go toward abortions.
Representative Kevin McCarthy of California, the leader of the Republican majority in the House, has asked Tom Price, the new secretary of Health and Human Services, to examine whether California's law violates laws protecting the religious freedom of health care providers who object to abortion.
Ms. Borchelt said other language in the proposal also moved to stop insurance companies from covering abortion. Under that language, health insurance plans could not be considered ''qualified,'' and therefore eligible to be sold on the individual market, if they covered abortion. Because insurance companies tend to set a lot of the same benefits in plans across their various markets, she said, ''the language is disincentive and meant to discourage plans from covering abortions.''
Republicans have argued that women can buy an additional rider on their insurance to cover abortion.
But, Ms. Borchelt said: ''No such plans exist. All those provisions work as a de facto ban on insurance coverage in every state with no real option to get it elsewhere.''
Most abortions are performed in the first trimester of pregnancy. The Kaiser Family Foundation estimates that an abortion at 10 weeks costs between $400 and $550.
The proposed replacement for the Affordable Care Act would mostly affect insurers offering plans in the individual market. But it would also affect employer-sponsored insurance plans in two ways. It would prevent tax credits used by small businesses to buy health insurance, as well as those used by people who have left their jobs to extend employer-sponsored insurance coverage, from being used to buy plans that cover abortion.
Employers might decide not to offer abortion coverage, knowing that their employees, if they left, could not use their tax credits to continue that policy.
Given the various restrictions across the country, Elizabeth Nash, a state policy analyst at Guttmacher, asked whether insurers might simply reach a point where it is standard not to cover abortion. ''Have we reached the tipping point where it's so complicated and cumbersome to provide it that insurers will simply stop?'' she asked. ''You can imagine insurers saying it isn't worth the hassle.''
URL: http://www.nytimes.com/2017/03/10/health/republican-health-plan-insurance-abortion-coverage.html
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March 23, 2016 Wednesday
Late Edition - Final
No Contraception? No Equality
BYLINE: By ELIZABETH DEUTSCH.
Elizabeth Deutsch is a student at Yale Law School.
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THE Supreme Court will hear a second challenge to the Affordable Care Act's contraceptive mandate on Wednesday in a case called Zubik v. Burwell. The plaintiffs want to extend the 2014 ruling in Burwell v. Hobby Lobby Stores, which recognized the right of certain for-profit companies to a religious exemption from the act's requirement that employers' health plans provide contraceptive coverage.
This time, the objection comes from a handful of religious nonprofits that argue that the government's religious exemption itself infringes on their religious freedom. The groups contend that filling out a one-page form or sending a letter to the government to get the exemption amounts to ''facilitation of sin'' because it starts a process that ultimately allows employees to get contraception though a third party.
This case is one of several recent conflicts in which one side seeks to use its religious objections to undermine laws that promote equality. The position taken by the plaintiffs in Zubik recalls the refusal last year by a Kentucky county clerk to issue marriage licenses to same-sex couples after the Supreme Court's marriage-equality ruling.
At first, Zubik might not look like the Kentucky showdown, but there is a similar dynamic at play. The real issue at stake in reproductive rights cases, as Ruth Bader Ginsburg put it in 1978, paraphrasing another scholar when she was herself a professor, is whether women are ''to have the opportunity to participate in full partnership with men in the nation's social, political and economic life.''
In dismissing one of the claims that the Supreme Court will hear oral argument about on Wednesday, the United States Court of Appeals for the District of Columbia made a similar point: ''For most women, whether and under what circumstances to bear a child is the most important economic decision of their lives. An unintended pregnancy is virtually certain to impose substantial, unplanned-for expenses and time demands on any family, and those demands fall disproportionately on women.''
Access to reproductive care is central to equality between the sexes. By requiring employers' health plans to provide contraceptive coverage, the Affordable Care Act represents an important legislative link between sex equality and reproductive rights. Before it was passed, women were paying more for health care than men largely because of the cost of reproductive health coverage.
Congress made a deeper commitment to anti-discrimination rights in health care in another provision of the Affordable Care Act that is not under review in this case. Section 1557 gives patients an opening to sue in federal court if they experience discrimination at the hands of health care providers, insurers or other related programs. In defining the forbidden forms of sex discrimination, the law implicitly includes pregnancy discrimination. By doing so, the provision connects women's reproductive capacity to equality between the sexes.
In the Affordable Care Act, Congress extended federal anti-discrimination protections for the first time to reproductive-age women at hospitals, community health centers and residential treatment centers, and in insurance markets. In that way, the law represents a profound commitment to the idea that the inability to gain access to health care, including reproductive care, can be a form of discrimination. The statute recognizes different bodies -- women's bodies -- as deserving of equal care in ways that, to date, the Supreme Court has not.
In fact, the Supreme Court has repeatedly failed to see how women's access to reproductive care has implications for their status as legal equals. This is partly, perhaps, an accident of history: The court considered contraception before it articulated a constitutional right to be free from state-sanctioned sex discrimination. This may be one reason the court originally struck down state bans on contraception through privacy-based reasoning rather than equality-based reasoning.
But the Supreme Court's blindness to the implications for women's equality in its rulings on reproductive rights persisted. In 1974, in Geduldig v. Aiello, the court rejected the constitutional sex discrimination claims of female employees who had been denied coverage for pregnancy-related disabilities under their state-issued insurance. Unfavorable treatment based on pregnancy, the court reasoned, didn't count as sex discrimination because the policy did not distinguish between women and men, but between ''pregnant women and nonpregnant persons,'' as though pregnancy had nothing to do with sex. The court doubled down two years later in General Electric Company v. Gilbert, denying the same claims under Title VII, the federal law that bans sex discrimination in employment.
The Supreme Court appeared to walk back its formalistic view, first in Planned Parenthood of Southeastern Pennsylvania v. Casey, the 1992 abortion case, when it reasoned that the ''ability of women to participate equally in the economic and social life of the nation has been facilitated by their ability to control their reproductive lives,'' and then in Nevada Department of Human Resources v. Hibbs in 2003, when it recognized that gender-neutral family-leave protections promoted women's work-force participation by decoupling reproductive capacity from child care. But in 2012, in Coleman v. Maryland Court of Appeals, the court failed to see how other federal leave policies furthered the same interest.
And again in Hobby Lobby, the court did not see the refusal to provide contraception as sex discrimination, in part because women could theoretically still get coverage by the alternate procedure that is being challenged in Zubik.
Nonetheless, the majority maintained that while some employers could opt out of providing contraception on religious grounds, the holding did not ''provide a shield for employers who might cloak illegal discrimination as a religious practice.''
But federal laws, repeatedly repudiating the court's limited view of sex equality, emphasize that sex discrimination is exactly what's at stake. The back-and-forth started a few years after the court's rulings in Geduldig and Gilbert, when Congress passed a law to ensure that federal workplace protections defined sex discrimination to include pregnancy discrimination. This more robust definition of sex discrimination also applies to students through regulations under Title IX. The Affordable Care Act is the latest law in this tradition to recognize the implications for sexual equality of reproductive care.
Difficult questions surely arise when reproductive rights conflict with religious beliefs. But as it weighs religious objections to contraception coverage, the Supreme Court should recognize that it is only when women's health care rights are fully recognized by the law that women can participate in society as equals.
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URL: http://www.nytimes.com/2016/03/23/opinion/no-contraception-no-equality.html
LOAD-DATE: March 23, 2016
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December 25, 2013 Wednesday
Late Edition - Final
Sign-Up Period Extended Again For Health Plan
BYLINE: By ROBERT PEAR; Sarah Wheaton contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1240 words
WASHINGTON -- The Obama administration said Tuesday that it would provide more time for people to complete their applications for health insurance if they could show that they missed the deadline because of problems with the federal health care website.
The move was the latest in a series of deadline changes, exemptions and clarifications that have confused insurers and many Americans and opened the administration to increasing criticism from Republicans who have opposed the Affordable Care Act from the start and have repeatedly tried to overturn it.
It was not clear on Tuesday how many people would be affected, or how consumers would prove that website errors had prevented them from signing up by the deadline on Tuesday night.
The announcement itself was vague, saying only that if website problems had prevented any consumers from enrolling, they might qualify for what the government has called ''a special enrollment period.'' The administration did not say how long that would last. Nor did it define what website errors might be involved.
Republicans said the announcement -- coming a day after the federal website recorded more than two million visits -- showed that President Obama was desperate to increase enrollment, widely seen as a measure of the success of the health care law.
For their part, administration officials said the move was a common-sense response to heavy traffic on the website, which they cited as evidence of a huge need for more affordable insurance. Some 48 million Americans are uninsured. Many could qualify for subsidized coverage under the Affordable Care Act.
Tara McGuinness, a White House spokeswoman, said the administration was not providing ''a blanket extension,'' but was offering to provide ''assistance to individuals on a case-by-case basis.''
And Kurt DelBene, the new troubleshooter for the site, said it was performing well. ''With the highest volumes we have seen to date, response time is fast, and the error rate is low,'' he said.
The move did not mollify insurers who have grown concerned as new problems have erupted since the rollout on Oct. 1 and are worried about how they will be able to provide coverage for everyone who wants it by Jan. 1, when that coverage is supposed to go into effect.
''The goal posts keep moving,'' William G. Schiffbauer, a lawyer who represents insurance companies, said Tuesday evening. ''That raises questions about whether insurers can collect premiums in a timely manner to pay claims from doctors and hospitals.''
''The latest step creates confusion for consumers and insurers,'' he added.
Insurers said that Tuesday's action, combined with several recent unexpected shifts in federal rules and policy, made it harder for them to predict the number and characteristics of new subscribers. That, in turn, makes it harder for them to predict their costs and complicates efforts to set prices for their products.
In general, insurance companies say they need substantial numbers of healthy people to balance the financial risks of covering older Americans who require more medical care.
The open enrollment period continues to March 31. People who select health plans on the federal exchange starting Wednesday and continuing through Jan. 15 will generally be entitled to coverage that takes effect on Feb. 1, provided they pay their share of the first month's premium before then.
The new offer to consumers who have had trouble with the website followed the last-minute surge of interest among people seeking coverage, and the administration hailed what it described as ''amazing interest'' in new health insurance options.
The original deadline for coverage starting Jan. 1 was Dec. 15. On Nov. 22, the deadline was extended to Dec. 23. On Monday, the White House provided a 24-hour grace period, to 11:59 p.m. on Tuesday.
Then on Tuesday, in a bid to ensure coverage for all who want it, the administration provided details of the ''special enrollment period'' for some people -- but not all -- who miss the deadline.
''If you weren't able to enroll in an insurance plan by Dec. 23 because of problems you had using HealthCare.gov, you still may be able to get coverage that starts Jan. 1,'' the administration told visitors to the website in a message posted on the health insurance blog at HealthCare.gov. The message also highlighted the assistance available to shoppers.
''Couldn't enroll by December 23?'' it said. ''We can still help you get covered.''
''Even though we have passed the December 23 enrollment deadline for coverage starting January 1, we don't want you to miss out if you've been trying to enroll,'' the administration said. ''Sometimes despite your best efforts, you might have run into delays caused by heavy traffic to HealthCare.gov, maintenance periods or other issues with our systems that prevented you from finishing the process on time. If this happened to you, don't worry -- we still may be able to help you get covered as soon as January 1.''
If consumers want to plead their case, the administration said, they can call a special number (800-318-2596) and explain why they could not complete their applications in time.
''Tell our customer service representative that you've been trying to enroll and explain why you couldn't finish by the deadline,'' the website advises consumers. ''They can tell you what you can do to finish your enrollment and still get covered for 2014.''
The administration did not set a deadline for such requests. The call center is normally open around the clock but is closed on Christmas, officials said.
Ms. McGuinness, the White House spokeswoman, said there were ''10,000 call center workers working tonight on Christmas Eve to get people health insurance before the final deadline.'' Julie Bataille, a spokeswoman at the federal Centers for Medicare and Medicaid Services, said people who had problems with the website before Tuesday could receive ''individual assistance'' if they contacted the call center.
In its effort to help consumers and to avoid political damage to the president, the administration has announced a series of policy changes, delays, extensions and clarifications in recent months.
Taken together, they amount to a sweeping exercise of executive power -- what Prof. Jonathan Turley of George Washington University Law School describes as a ''pattern of circumventing Congress in the creation of new major standards, exceptions or outright nullifications.''
In July, the White House deferred, until 2015, a requirement for larger employers to offer coverage to employees or pay penalties. In mid-November, Mr. Obama asked insurers to reinstate policies being canceled because they did not comply with minimum coverage requirements of the law.
A week later, the administration extended the initial deadline for people to sign up for coverage that starts in January. A few days after that, health officials announced a one-year delay in online enrollment for small businesses using the federal insurance exchange. The administration then moved the sign-up deadline for individuals to Dec. 23 and extended by one month, to the end of January, a special insurance program for people with serious illnesses.
Kathleen Sebelius, the secretary of health and human services, announced last week that people facing the cancellation of individual policies could buy cheaper catastrophic coverage on the exchange and would be exempt from penalties if they went without insurance next year.
URL: http://www.nytimes.com/2013/12/25/us/politics/white-house-again-stretches-health-care-sign-up-deadline.html
LOAD-DATE: December 25, 2013
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: President Obama, on his way to play golf on Tuesday in Hawaii, is desperate to increase insurance enrollment, Republicans say. (PHOTOGRAPH BY KEVIN LAMARQUE/REUTERS) (A18)
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The New York Times
November 16, 2016 Wednesday
Late Edition - Final
Expect Medicaid to Change, but Not Shrivel, in New Administration
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 1243 words
WASHINGTON -- The expansion of Medicaid, a central pillar of the Affordable Care Act, faces immense uncertainty next year, with President-elect Donald J. Trump and top Republicans in Congress embracing proposals that could leave millions of poorer Americans without health insurance and jeopardize a major element of President Obama's legacy.
But influential figures in surprising quarters of the new administration might balk at a broad rollback of Medicaid's reach, favoring new conditions for access to the government insurance program for the poor but not wholesale cutbacks.
Mike Pence, the vice president-elect, is proud of the Medicaid expansion he engineered as governor of Indiana, one of 31 states that expanded eligibility under the Affordable Care Act. The Indiana program has conservative features that emphasize ''personal responsibility'' and require Medicaid beneficiaries to make monthly contributions to savings accounts earmarked for health care.
Another Trump adviser, Gov. Chris Christie of New Jersey, hails the expansion of Medicaid in his state, saying more than half a million people are receiving ''more and better health care.'' The federal government pays the full cost for newly eligible beneficiaries from 2014 through 2016 and at least 90 percent of the costs in later years under the health law.
It is hard to overstate the importance of Medicaid, which insures 77 million people, pays for more than half of all births in some states, covers about two-thirds of nursing home residents and provides treatment for many people addicted to opioids. Spending on Medicaid, by the federal government and states combined, exceeds $500 billion a year.
Of the 20 million people who have gained coverage under the Affordable Care Act, officials estimate, 12 million are insured by Medicaid -- with few of the problems that have plagued the new insurance exchanges, or marketplaces.
But change is coming. In his campaign manifesto, Mr. Trump said Congress must repeal the Affordable Care Act and give each state a lump sum of federal money -- a block grant -- for Medicaid. Congress passed legislation in January to repeal the health law and roll back its Medicaid expansion. Mr. Obama vetoed the measure, but Speaker Paul D. Ryan of Wisconsin has vowed to put similar legislation on a Republican president's desk.
Without even waiting for legislation, the Trump administration is almost certain to give states more leeway to run their Medicaid programs as they wish, federal and state officials say.
A number of states have already proposed co-payments and work requirements for people on Medicaid.
In an effort to protect beneficiaries, the Obama administration has limited the use of co-payments and has not allowed work requirements. But state officials say that such changes are likely to be allowed in some form in a Trump administration.
Cindy Gillespie, the director of the Arkansas Department of Human Services, said that with the election of Mr. Trump, she saw ''a real chance for states to take back a bit of control over Medicaid and other safety net programs.''
Darin Gordon, who stepped down in June after 10 years as the director of Tennessee's Medicaid program, predicted that ''there will be greater receptivity in the new administration to state proposals that were shut down by the Obama administration.''
Cindy Mann, the top federal Medicaid official from 2009 to January 2015, said it was entirely possible that a Trump administration would ''make different judgments'' about Medicaid waivers, the vehicle for a wide range of state innovations and experiments. The federal government has broad discretion to approve state demonstration projects if the secretary of health and human services finds they are ''likely to assist in promoting the objectives'' of the Medicaid program.
On Nov. 1, the Obama administration rejected a waiver request from New Hampshire, which wanted to impose a work requirement and more stringent standards for Medicaid beneficiaries to show they were United States citizens and residents of the state. The requirements ''could undermine access, efficiency and quality of care,'' the administration said.
New Hampshire will have a Republican governor for the first time in 12 years and could submit similar proposals to the Trump administration.
In September, the Obama administration approved a waiver allowing Arizona to charge premiums to people with incomes above the poverty level ($20,160 a year for a family of three). But federal officials refused to allow work requirements or a time limit on coverage, and they said the state could not charge premiums to people below the poverty level.
The Obama administration also rejected Ohio's request for a waiver to charge premiums and suspend coverage for people who failed to pay them, a policy it said would jeopardize coverage for more than 125,000 people.
In Kentucky, where more than 400,000 people have gained coverage because of the expansion of Medicaid, Gov. Matt Bevin, an outspoken Republican critic of the health law, is seeking federal approval for a waiver allowing work requirements, premiums and co-payments.
Negotiations over a proposed Medicaid block grant would need to answer difficult questions: How is the amount of the initial federal allotment determined? Will this amount be adjusted to reflect population growth, the effect of an economic downturn, or increases in the cost of medical care or in consumer prices generally? Will it be adjusted to reflect the advent of costly but effective drugs like those to treat hepatitis C? Will states have to continue spending their own money on Medicaid? Will Medicaid beneficiaries still have a legally enforceable right -- an entitlement -- to coverage and care if they meet eligibility criteria set by the federal government and states?
Medicaid block grants have been a favorite of Republicans in Washington, proposed in various forms by President Ronald Reagan in 1981, congressional Republicans in 1995 and President George W. Bush in 2003.
The House Republicans' ''Better Way'' agenda, unveiled in June, would give states a choice of a fixed allotment for each Medicaid beneficiary or a block grant for Medicaid. Either way, states would get less money than they expect to receive under current law.
Under the proposal for a per-capita allotment, states that had not expanded eligibility as of January 2016 would not be able to do so. The enhanced federal payments that states now receive for newly eligible Medicaid beneficiaries would be reduced, and many states would have difficulty making up the difference.
Under the Affordable Care Act, the federal government is scheduled to pay 93 percent of Medicaid costs for newly eligible beneficiaries in 2019. Under the House Republican plan, the federal share would be pared back to its regular levels -- now, for example, 70 percent in Arkansas, 62 percent in Ohio and 50 percent in New Jersey.
The budget bill pushed through Congress by Republicans but vetoed by Mr. Obama in January would have repealed the expansion of eligibility.
Appearing on Sunday on the CNN program ''State of the Union,'' Mr. Ryan said House Republicans wanted to replace the expansion of Medicaid with ''refundable tax credits for people to buy affordable health care insurance.''
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URL: http://www.nytimes.com/2016/11/16/us/politics/trump-medicaid-health-care.html
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The New York Times
December 27, 2013 Friday
Late Edition - Final
2 States May Seek Refunds From Health Site Creator
BYLINE: By RICK LYMAN; Ian Austen contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 754 words
Two states that hired the same lead contractor to build their online marketplaces for health insurance under President Obama's Affordable Care Act have experienced so many problems and delays that they are threatening to withhold millions of dollars in payments to the company and even seek refunds.
Massachusetts health officials said they will meet in early January to decide whether to suspend payments to the company, CGI Federal, which has also been criticized -- and questioned during a congressional hearing -- for its central role in building the problem-plagued federal health insurance exchange. The state may also seek a refund from the firm, which is an American subsidiary of the Canadian-based CGI Group.
Already, Vermont has refused to pay $5.1 million of its contract with the company and is trying to get hundreds of thousands of dollars refunded. The two states' problems with CGI were reported by The Boston Globe.
Under the Affordable Care Act, eligible Americans who do not have health insurance through their workplace or another source can sign up for coverage through a health care exchange that will provide a menu of options and information on subsidies. Open enrollment runs through March; those who have not signed up by then could face penalties.
Fourteen states, including Massachusetts and Vermont, created their own online marketplaces, and the rest depend on the exchange operated by the federal government.
While the federal site had a rocky rollout on Oct. 1, several of the state exchanges also stumbled. In Hawaii, the site created by CGI performed so poorly that the head of the exchange stepped down this month. Other exchanges -- including Kentucky's and California's, on which CGI worked as a subcontractor -- have performed relatively well.
''Right now, our current focus is ensuring there are no gaps or delays in coverage for our members,'' said Jason Lefferts, a spokesman for Massachusetts Health Connector, the state's insurance exchange. ''We will be coming back to the board in January to discuss further accountability for the I.T. vendor, and also talk about the path forward.''
Massachusetts has already paid CGI $11 million under a $69 million contract.
Mr. Lefferts said that the exchange continued to perform slowly and that people had ''recurring problems'' creating accounts and logging in. ''We still don't have the automated ability to process an application and determine someone's eligibility,'' he said. ''We also don't have the ability to send enrollment information directly to the insurance carrier.''
Lorne Gorber, senior vice president for global communications and investor relations at the CGI Group, said: ''The goal of the clients and the goal of ourselves is the same: that's to get everything right and not be wasting a lot of time and effort in the clauses of the contracts when we're doing that.''
Noting that CGI is involved in nine state exchanges, he said, ''It's expected that some of them are not the best performing ones.''
''It's important to note that we're not at the bottom of the worst performing ones,'' he added, ''and we're at the top of the list of the best performing ones.''
The exchange's performance has been especially nettlesome in Massachusetts, which had its own online health insurance system before the Affordable Care Act. Because the federal law required so many extra features, the state decided to build a new website -- which is now malfunctioning.
In Vermont, Gov. Peter Shumlin has frequently expressed frustration with his state's insurance exchange, complaining of repeated delays since its unveiling.
''I won't tolerate a situation where Vermonters go into the holiday season worried and confused by their health care options come January 1st,'' the governor said in late October, when problems with the state website forced him to delay some enrollment deadlines.
Continued trouble, though, has prompted Vermont to hold back a $5.1 million payment and threaten to withhold more if the problems are not fixed. So far, the state has paid only $19 million of its $83 million contract with CGI.
Mark Larson, Vermont's commissioner of health access, sent CGI two letters last month contending that the company had failed to deliver on its contract by missing critical deadlines and charging for services never performed, among other things.
''Most importantly,'' Mr. Larson wrote, ''CGI has yet to provide the state of Vermont with a fully functioning website. Vermont residents still cannot buy their health plans online, as promised.''
URL: http://www.nytimes.com/2013/12/27/us/2-states-may-seek-refunds-from-health-site-creator.html
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The New York Times
March 25, 2017 Saturday
Late Edition - Final
President's Choice: Repair Obamacare, or Ruin It
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; PUBLIC HEALTH; Pg. 13
LENGTH: 1105 words
President Trump and a Republican-led Congress tried and failed to repeal the Affordable Care Act. Now, they have to decide whether they want to work with it or sabotage it.
Both Mr. Trump and congressional leaders acknowledged on Friday that they would not bring their repeal bill back for a vote any time soon. That means that, as Speaker Paul Ryan said, ''we're going to be living with Obamacare for the foreseeable future.''
Mr. Ryan and Mr. Trump reiterated their criticisms of the law and set the stage for watching it collapse and blaming the Democrats for the aftermath. ''I've been saying for the last year and a half that the best thing we can do politically speaking is let Obamacare explode,'' Mr. Trump said from the Oval Office. ''It is exploding now.''
Mr. Ryan said that Obamacare's architects would be sad that the bill was allowed to live on, given what he described as its inevitable failure.
In fact, Obamacare is not on the verge of ''explosion.'' Enrollment in its insurance marketplaces is steady, and several independent analyses suggest that insurance prices have stabilized after a sharp market correction this year. But the structures it set up to provide health insurance to middle-income Americans are vulnerable. Insurance companies have struggled to make money in the early years of the new markets, and many have backed out. Others remain tentatively committed and skittish.
Mr. Trump will need to decide, quickly, whether his goal is to knock over the still-functioning markets, or help prop them up. If he decides to topple them, next year could be very messy.
Insurers are making their decisions right now about whether to enter the markets for next year and about how much to charge their customers. Signals from the administration in the next few weeks about whether he will help or hurt them will almost certainly guide insurers' choices.
Fight a court case on subsidies?
The biggest immediate decision concerns a court dispute between the House and the administration over subsidies to help low-income insurance buyers pay their deductibles and co-payments. The House has argued that the money for those subsidies was not properly authorized. The Obama White House fought the case. It is not clear whether Mr. Trump's lawyers will do the same. The availability of those subsidies, used by a majority of Obamacare customers, is critical for insurers in the markets.
Without the subsidies, all the insurers will lose some money, and many smaller carriers will face bankruptcy. If Mr. Trump does not fight the court case, the Obamacare markets in most states will unravel quickly, leaving millions without insurance options on his watch. Many of the beneficiaries are Trump voters.
Encourage insurance companies in wobbly markets?
There are smaller decisions ahead, too, about how to administer programs, whether to enforce the law's individual mandate, and whether to recruit insurers to participate in markets where competition is thin.
So far, Mr. Trump's secretary for health and human services, Tom Price, has taken every opportunity to gloat about the health law's setbacks, even as he is administering its programs.
Mr. Price, perhaps more than Mr. Trump, has long been committed to the Affordable Care Act's demise. But now he will have to manage the law's many programs. Obama administration officials called insurers, cajoling and reassuring them. If Mr. Trump wants the markets to be vigorous, he could use his self-described deal-making skills to woo insurance companies into the stabilizing markets.
Make the system more conservative?
If Mr. Trump and Mr. Price can make peace with the health law, there are opportunities to steer it in a more conservative direction. The law gives broad authority to the executive branch to shape health care policy. So far, the health law has been driven by Obama administration priorities, but that could change.
A few early regulatory changes have begun that process. The Trump administration plans to make it harder for people to sign up for plans midyear. It has given insurers more wiggle room to raise their deductibles. It may be able to make alterations that loosen up benefit requirements -- though it won't be able to completely eliminate them, as Republicans sought to do at the last minute in the failed bill.
Offer states maximum flexibility?
The administration will also have enormous power to allow states to reshape their Medicaid programs -- and even their local insurance markets -- through waivers to existing law. Seema Verma, the just-confirmed administrator of the Centers for Medicare and Medicaid Services, was a consultant who helped states write pathbreaking conservative proposals for their Medicaid programs. She is ideally positioned to approve many more such waivers from Republican-led states, allowing them to impose premiums, cost-sharing and even work requirements for Medicaid beneficiaries.
A new Obamacare waiver program has just gone into effect: It would allow states to overhaul their entire health insurance markets if they can show that their revised plans would cover as many people. That process could allow Ms. Verma and Mr. Price to approve state plans that hew more closely to the Republican vision for health care.
Change Medicare policy?
New powers granted under the Affordable Care Act allow the Department of Health and Human Services to make major changes to the Medicare program, through demonstration projects meant to lower costs and improve patient care. The Obama administration set a precedent of imposing ''mandatory'' projects on large portions of the country to test policy ideas. So far, Mr. Price has looked askance at such efforts. But the provision could give him power to reshape what Medicare pays for and how seniors receive their care.
Nicholas Bagley, a law professor at the University of Michigan, has criticized the Obama administration for stretching its legal authority with some of its Obamacare choices. But those choices have created a precedent for the Trump administration to stretch the health law in its own direction. ''If you think Congress is done, and you don't want to provoke a reaction anymore, then you own this,'' he said. ''You will be judged as an executive on the performance of Obamacare.''
For years, opposing Obamacare has been a rallying cry for Republicans. But if Republicans can't repeal Obamacare, they could instead co-opt it. There are opportunities for Trumpcare yet.
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URL: http://www.nytimes.com/2017/03/24/upshot/trumps-choice-on-obamacare-sabotage-or-co-opt.html
LOAD-DATE: March 25, 2017
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GRAPHIC: PHOTO: Supporters of the Affordable Care Act outside the White House on Tuesday. President Trump said the law is ''exploding now.'' (PHOTOGRAPH BY MANDEL NGAN/AGENCE FRANCE-PRESSE -- GETTY IMAGES)
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The New York Times
January 24, 2017 Tuesday 00:00 EST
Tom Price's Heated Hearing Is Unlikely to Derail His Nomination
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 1377 words
HIGHLIGHT: Democrats pressed Mr. Price, the nominee for health and human services secretary, on ethics and the Affordable Care Act, but his support from Republicans is solid.
WASHINGTON - In a heated confirmation hearing that focused on ethical issues, President Trump's nominee for secretary of health and human services, Representative Tom Price, defended his trading of medical and pharmaceutical stocks on Tuesday, saying, "Everything that I did was ethical, aboveboard, legal and transparent."
Democrats accused Mr. Price of a potential conflict of interest at a hearing of the Senate Finance Committee, saying he held more than $100,000 in stock in companies that could have benefited from legislation he promoted. Mr. Price, a Georgia Republican, denied any wrongdoing.
He also avoided being pinned down on the future of the Affordable Care Act, Medicare and Medicaid, programs that insure more than 100 million people.
While Mr. Price faced vigorous questioning from Democrats, he and other cabinet nominees have benefited from solid support among Republicans, who hold a 52-48 majority in the Senate.
But some nominees had bipartisan support. By a vote of 96 to 4, the Senate approved the nomination of Gov. Nikki R. Haley of South Carolina to be ambassador to the United Nations.
Senator Benjamin L. Cardin of Maryland, the senior Democrat on the Foreign Relations Committee, praised Ms. Haley for "moral clarity," noting that she had declared that the Russians were guilty of war crimes in bombing the Syrian city of Aleppo - an assertion that Rex W. Tillerson, Mr. Trump's choice for secretary of state, declined to make.
Senate committees endorsed other nominations on Tuesday: Elaine L. Chao for transportation secretary, Wilbur L. Ross for commerce secretary and Ben Carson for secretary of housing and urban development.
Linda McMahon, selected by Mr. Trump to lead the Small Business Administration, also sailed through her confirmation hearing. She was introduced and endorsed by the senators from her home state, Connecticut: Richard Blumenthal and Christopher S. Murphy, both Democrats.
The endorsements were notable because Ms. McMahon ran for the Senate and was defeated by Mr. Blumenthal in 2010 and Mr. Murphy in 2012.
Even as some nominees advanced, Republicans were becoming frustrated and angry. They said Democrats were delaying and prolonging the reviews, raising procedural objections without changing the likely outcome.
Senator John Cornyn of Texas, the No. 2 Senate Republican, accused the Democrats of "obstruction and foot-dragging" and said they were "attempting to litigate or re-litigate the election." Senator John Thune, Republican of South Dakota, said: "The president won an election. He deserves to get his people in place."
The hard feelings felt to some like payback. Democrats noted that Republicans had stalled many of President Barack Obama's picks and refused to act on his nomination of Judge Merrick B. Garland to the Supreme Court.
In the Senate Committee on Energy and Natural Resources, Democrats held up confirmation votes for two nominees: Representative Ryan Zinke of Montana for interior secretary and former Gov. Rick Perry of Texas for energy secretary. The Democrats said they had unanswered questions about important research programs at the Energy Department.
Democrats on the Finance Committee put Mr. Price through three and a half hours of grueling interrogation. But they appeared unlikely to block his confirmation unless other damaging information comes to light.
"We've always known where the votes are," said Senator Ron Wyden of Oregon, the senior Democrat on the committee. The panel could vote next week on whether to recommend confirmation, with its Republican majority strongly supporting Mr. Price.
Mr. Price was asked about an executive order issued by Mr. Trump on Friday that tells federal officials to provide relief from costs, penalties and regulatory burdens imposed on consumers, insurers and health care providers by the Affordable Care Act.
Mr. Wyden asked Mr. Price if he would promise that no one would be worse off and no one would lose coverage as a result of the order. Mr. Price declined to provide an explicit assurance. He promised instead to work with Congress to "make certain that we have the highest-quality health care and that every single American has access to affordable coverage."
Senator Maria Cantwell, Democrat of Washington, said the administration appeared to be planning a "war on Medicaid." Mr. Price rejected that description, saying he wanted to give states more control over Medicaid, which covers more than 70 million low-income people.
Senator Dean Heller, Republican of Nevada, asked Mr. Price for a commitment that any replacement for the Affordable Care Act would allow states to continue the expansion of Medicaid eligibility already approved by Nevada and 30 other states.
Mr. Price deferred to Congress, saying, "This is a policy question that needs to be worked out through both the House and the Senate." He said he wanted to ensure that people "who are currently covered through Medicaid expansion either retain that coverage or in some way have coverage through a different vehicle."
In any event, he said, "every single individual ought to be able to have access to coverage."
He added that many people had Medicaid coverage but could not find doctors to treat them.
"One out of three physicians who ought to be able to see Medicaid patients in this nation do not take any Medicaid patients" because of low reimbursement rates, burdensome regulations or the "hassle factor," Mr. Price said.
Mr. Price has led efforts to repeal the Affordable Care Act. He refused on Tuesday to say whether he would fight to preserve the expanded coverage of prescription drugs provided to Medicare beneficiaries under the law. Rather, he said, "it is imperative we provide the greatest amount of opportunity for individual seniors to be able to gain access to the drugs that they need."
That answer did not satisfy Senator Bill Nelson, Democrat of Florida, which is home to more than four million Medicare beneficiaries. "If I gave them that answer," Mr. Nelson said, "I would get run out of the room with a group of senior citizens."
Mr. Price also declined to say how he would carry out Mr. Trump's promise to drive down prescription drug prices. Mr. Trump has said he will do so by negotiating with drug manufacturers and by requiring them to bid for government business.
A background investigation of Mr. Price found that he had understated the value of his investments in an Australian pharmaceutical company and claimed income tax deductions that he could not substantiate. The findings emerged from a review of his tax returns and other official documents by Finance Committee staff members from both parties.
In a questionnaire in December, the staff said, Mr. Price understated the value of 400,613 shares of the Australian company, Innate Immunotherapeutics, that he purchased in August through "a private placement offering."
"It's hard to see how this can be anything but a conflict of interest and an abuse of his position," Mr. Wyden said. But Mr. Price said that he did not have any "nonpublic information" about the company. And the committee chairman, Senator Orrin G. Hatch, Republican of Utah, said the Democrats' attacks on Mr. Price's ethics were "specious and distorted."
The committee staff added that Mr. Price had taken "improper deductions on his 2016 tax returns" for the depreciation of land associated with condominiums he owns in Washington and Nashville. He and his wife, both physicians, also claimed "miscellaneous employment deductions totaling $19,034" for expenses in 2013, 2014 and 2015, the staff said. But "proper documentation could not be located," so his returns will be amended.
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Thomas Kaplan and Emmarie Huetteman contributed reporting.
PHOTO: Representative Tom Price testified before the Senate Finance Committee on Tuesday in a hearing focused on ethical issues. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES)
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Tom Price, Obamacare Critic, Is Trump's Choice for Health Secretary
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May 26, 2014 Monday
Late Edition - Final
Hospitals Look to Health Law, Cutting Charity
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1160 words
Hospital systems around the country have started scaling back financial assistance for lower- and middle-income people without health insurance, hoping to push them into signing up for coverage through the new online marketplaces created under the Affordable Care Act.
The trend is troubling to advocates for the uninsured, who say raising fees will inevitably cause some to skip care rather than buy insurance that they consider unaffordable. Though the number of hospitals tightening access to free or discounted care appears limited so far, many say they are considering doing so, and experts predict that stricter policies will become increasingly common.
Driving the new policies is the cost of charity care, which is partly covered by government but remains a burden for many hospitals. The new law also reduces federal aid to hospitals that treat large numbers of poor and uninsured people, creating an additional pressure on some to restrict charity care.
In St. Louis, Barnes-Jewish Hospital has started charging co-payments to uninsured patients, no matter how poor they are. The Southern New Hampshire Medical Center in Nashua no longer provides free care for most uninsured patients who are above the federal poverty line -- $11,670 for an individual. And in Burlington, Vt., Fletcher Allen Health Care has reduced financial aid for uninsured patients who earn between twice and four times the poverty level.
By tightening requirements for charity care, hospital executives say, they hope to encourage eligible people to obtain low-cost insurance through the subsidized private plans now available under the law.
''Do we allow our charity care programs to kick in if people are unwilling to sign up?'' said Nancy M. Schlichting, chief executive of the Henry Ford Health System in Detroit. ''Our inclination is to say we will not, because it just seems that that defeats the purpose of what the Affordable Care Act has put in place.''
But advocates for the uninsured point out that many Americans avoided obtaining coverage in the inaugural enrollment period of the Affordable Care Act this year because they found the plans too expensive, even with subsidies. Many uninsured people also remain unaware of the new insurance options, And immigrants who are in the country illegally are not even eligible to apply.
''Certainly we want to encourage people who have new access to affordable coverage to take advantage of it,'' said Sidney D. Watson, a professor at St. Louis University's Center for Health Law Studies. ''But I think we're all going to have to do a lot to get that message out, and there will always be people who won't have the option.''
Beverly Jones, 51, of St. Louis, who has lupus, is the type of person targeted by Barnes-Jewish Hospital's new policy. Ms. Jones, who already owes Barnes-Jewish thousands of dollars for emergency room treatment and other visits, said the hospital's new co-payments for the uninsured would ''throw my budget into a tailspin'' on her annual income of $13,400, which comes mostly from disability checks.
She has enrolled in a subsidized insurance policy under the Affordable Care Act. But she worries that she will have trouble paying the fees and deductibles required under her new plan, even with generous subsidies.
''There's still a lot of stuff I can't afford to do,'' she said.
Many hospitals appear focused on reducing aid only for patients who earn between 200 percent and 400 percent of the poverty level, or between $23,340 and $46,680 for an individual. Many of those people presumably have jobs and would qualify for subsidized coverage under the new law.
BJC HealthCare, the nonprofit system that owns Barnes-Jewish and 11 other hospitals in Missouri and Illinois, gives all uninsured patients a 25 percent discount on the billed charges, regardless of their income. But the system previously provided additional discounts to uninsured patients with incomes up to 400 percent of the federal poverty level. Now, only patients earning up to 300 percent of the poverty level, or $35,010 for an individual, are eligible.
And for the first time, everyone who gets financial assistance owes at least a small co-payment. For example, patients with incomes at or below the poverty level are now charged $100 for emergency care and $50 for an office visit.
''We didn't want to have a policy that would encourage people not to follow the mandate'' to get health insurance, said June Fowler, a spokeswoman.
In the past, Southern New Hampshire Medical Center generally provided free or discounted care for patients who were at or below 225 percent of the poverty level, or about $26,260 for an individual. But starting this year, only patients below the poverty level will receive such charity care, said Paul Trainor, the system's vice president of finance.
Patients ''who refuse to purchase federally mandated health insurance when they are eligible to do so will not be awarded charitable care,'' the hospital's revised policy states.
Fletcher Allen, Vermont's largest health care system, changed its policy on April 1, requiring many uninsured patients to pay a percentage of their bill instead of a fixed fee of up to $1,000. Patients earning 200 percent of the poverty level or less will not be affected by the change, said Shannon Lonergan, Fletcher Allen's director of registration and customer service. But those earning between 201 percent and 400 percent of the poverty level will now have to pay between 15 percent and 45 percent of their bill, depending on their income.
Ms. Lonergan said the new policy would affect only about a third of its financial aid recipients. At BJC HealthCare, only about 3 percent of charity care patients in 2012 earned more than 300 percent of the poverty level and thus would no longer qualify for financial assistance unless there were extenuating circumstances, Ms. Fowler said.
Officials at both Fletcher Allen and BJC HealthCare said they had worked hard to inform patients about new insurance options during the recent enrollment period and to help them enroll in coverage. Both systems provide financial aid to lower-income people with high insurance costs.
The financial challenges are particularly daunting in the more than 24 states that have not yet expanded Medicaid, including Missouri. The Affordable Care Act reduces federal aid for uncompensated care on the assumption that hospitals would replace much of the lost income with payments for patients newly covered by Medicaid.
But the Supreme Court in 2012 gave states the right to opt out of the expansion. Now hospitals that treat the poor and uninsured in states like Missouri are losing federal aid without getting new Medicaid payments, a problem they say is threatening their bottom lines. Robert Hughes, the president and chief executive of the Missouri Foundation for Health, an independent philanthropic group, said BJC HealthCare was ''in a tough spot'' because of the state's refusal to expand Medicaid.
URL: http://www.nytimes.com/2014/05/26/us/hospitals-look-to-health-law-cutting-charity.html
LOAD-DATE: May 26, 2014
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GRAPHIC: PHOTOS: Beverly Jones, who has lupus, said new charges would ''throw my budget into a tailspin'' on her annual income of $13,400.
The Barnes-Jewish Hospital in St. Louis has started charging all of its uninsured patients small co-payments. (PHOTOGRAPHS BY AUGUST KRYGER FOR THE NEW YORK TIMES) (A12)
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The New York Times
January 11, 2017 Wednesday 00:00 EST
A Senate Vote-a-Rama Primer, in Case You Plan to Sleep Tonight
BYLINE: THOMAS KAPLAN
SECTION: US; politics
LENGTH: 741 words
HIGHLIGHT: As Republicans push forward with repealing the Affordable Care Act, lawmakers are about to undertake a grueling Senate tradition.
WASHINGTON - The Senate is getting ready for a very late night.
As Republicans push forward with repealing the Affordable Care Act, lawmakers are about to undertake a grueling Senate tradition: the vote-a-rama, a marathon of rapid-fire votes that is likely to stretch on for hours.
Yes, that's really what it's called.
For at least some people in the Capitol, like those who enjoy sleeping when it is nighttime, the experience will be unpleasant. But there is a reason for the spectacle.
For Democrats, it provides an opportunity to draw a distinction between their views on health care and how Republicans are approaching the issue. For Republicans, the completion of the exercise clears the way for them to advance to the next step in their quest to gut the health care law.
In lieu of the Congressional Budget Act of 1974, here is a primer on what to expect.
Will the health act be repealed while I sleep tonight?
No. Republicans have embarked on a fragile, multistep process to repeal major parts of the health care law, one that is on pace to at least take weeks, even without any big stumbles.
But an important step on the way to repealing the law could be taken soon, perhaps early Thursday. The Senate is close to approving a budget resolution that would set in motion the process of drawing up and ultimately passing legislation to repeal the act.
What's a budget resolution?
Don't be fooled by the name. In this case, Congress isn't working on the federal budget.
Republicans are taking a series of steps to allow them to repeal the health care law without facing a Democratic filibuster. Passing the budget resolution will set in motion the process that, as drawn up by Republican leaders, will culminate in the passage of legislation repealing major parts of the act.
The resolution will direct House and Senate committees to come up with that legislation. (There is some disagreement about the deadline for the committees to finish their work; Republican leaders planned for Jan. 27, but this week a group of five Republican senators suggested extending that date by five weeks, until March 3.)
The legislation that the committees come up with will be packaged in what is called a reconciliation bill, which is not subject to a filibuster. That's critical, because Republicans have a 52-seat majority, and overcoming a filibuster requires 60 votes.
Vote-a-what?
Special rules apply to budget resolutions. Senators can offer an unlimited number of amendments, and being generally crafty people, they like to take advantage of that opportunity.
The result is the spectacle known as the vote-a-rama. The Senate can consider dozens of amendments in quick succession, a task that can extend into the wee hours of the night.
None of the amendments hold the force of law: A budget resolution is essentially a blueprint for Congress, and the measure never goes to the president for a signature. But the amendments can be used to provide grist for campaign ads, giving each party the opportunity to force the opposing party's members to take votes on politically delicate topics.
The lengthy undertaking, with minimal debate about the amendments being voted on, is not the ideal deliberative experience.
Former Senator Judd Gregg, Republican of New Hampshire and a past chairman of the Senate Budget Committee, once described the vote-a-rama as "the Senate's equivalent to Chinese water torture."
What happens tonight?
The Senate is expected to begin the vote-a-rama Wednesday evening. Not surprisingly, Senate Democrats are expected to focus on amendments relating to health care law, as part of their effort to denounce the Republican push to unwind it.
It remains to be seen how long the vote-a-rama drama will go on. Senate Democrats have already displayed their stamina once this week: They spoke on the floor in defense of the law until past midnight on Monday night.
Once the amendments have been dealt with, the Senate is expected to approve the budget resolution, a key step toward the Republicans' goal of repealing the law.
Then what?
The House will take up the budget resolution, which it plans to do once the Senate gives its approval. The House vote could take place on Friday.
But some Republicans in the House have expressed unease with voting on the measure this week, because of uncertainty about when and how the health care law would be replaced.
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(In Practice)
September 30, 2013 Monday
Polls in Overtime on Affordable Care Act
BYLINE: Allison Kopicki
SECTION: US
LENGTH: 804 words
HIGHLIGHT: A series of polls show gaps in knowledge but more acceptance as consumers gain understanding of Affordable Care Act.
Several national and state polls have been released in the days leading up to the open enrollment period of the Affordable Care Act (A.C.A.). Here's a roundup of their findings:
The latestKaiser Health Tracking Pollfound widespread misconceptions about the health care law, including the notion that government panels would be set up to make decisions about end-of-life care for Medicare recipients - the so-called death panels.
Nearly two-thirds of those polled said they did not know that the health insurance exchanges were set to open on Oct. 1, including almost three-quarters of uninsured Americans. And half of Americans were under the impression that the law created a government-run insurance plan that would compete with private sector insurance plans.
Four in 10 Americans held the misconception that illegal immigrants would receive financial assistance to attain health insurance, and the same proportion said they believed the government would set up death panels.
Among the 51 percent of Americans who said they did not have enough information to know how the law would impact their family, financial concerns were at the forefront. When asked what their main question was about the health care law, one in five wanted to know about costs of plans and what enrollees would be expected to pay, followed by a desire for a basic summary of the law and how it will work.
A poll released by on Monday found that two-thirds of uninsured Americans said they would probably obtain health insurance by the Jan. 1, 2014, deadline, rather than pay a fine.
Under half of all uninsured said they planned on getting health insurance through a state or federal health insurance exchange. This low number may be because of a lack of knowledge of what the health exchanges are offering: more than 7 in 10 of uninsured said they were not too or not at all familiar with these health insurance exchanges.
And CNN/ORC released a poll on Monday that found a majority of Americans continued to oppose the health care law. However, 6 in 10 Americans say it is more important for Congress to approve a budget agreement and avoid a shutdown, rather than prevent the health care law from taking full effect by cutting funding.
Monmouth University released its first "Health Matters Poll" on Monday, finding that under half of New Jersey residents have a favorable view of the A.C.A. health care law. But residents of the Garden State have a slightly more positive outlook on the health care law and its impact on them personally than is held nationally, surveys conducted by Kaiser have found. The inaugural periodic survey of New Jersey on health issues was conducted Sept. 6-10 among 783 adults by landline and cellphone, with a margin of sampling error of plus or minus four percentage points.
The Kaiser Family Foundation also released a survey last week of uninsured adults in California, finding that one in five said they had never been covered by health insurance. Two-thirds said they had been without health insurance for at least two years. Four in 10 uninsured Californians said the health care law would increase their ability to attain health insurance and health care, but about a third said they did not think it would make a difference.
The poll, conducted before the start of an intense phase of outreach in the state about the health care expansion, found gaps in knowledge and some confusion among the uninsured about the health care law.
Kaiser Family Foundation conducted this baseline survey by landline and cellphone from July 11 to Aug. 29 among 2,001 adults in California who reported having been without health insurance coverage for at least two months at the time of the interview. This survey is the first in what is expected to be a four-wave panel to study the health care coverage choices that uninsured Californians make over the next two years, as California expands its Medi-Cal program and the state's insurance marketplace - Covered California - comes into being.
All national polls were conducted by landline and cellphone. The Gallup poll was conducted Sept. 17-26 among 5,099 adults, including 651 adults without health insurance, with a margin of sampling error of plus or minus two percentage points for all adults and five percentage points for uninsured adults. The Kaiser Family Foundation using landlines and cellphones among 1,503 adults from Sept. 12-18 with a margin of sampling error of plus or minus three percentage points. The CNN/ORC poll was conducted Sept. 27-29 among 803 adults, with a margin of sampling error of plus or minus four percentage points.
A Scramble as Day 1 Approaches
Answers to Some Questions About Health Care Exchanges
Picking a Plan and a Cobra Choice
Online Map Helps New Yorkers Understand Federal Health Law Benefits
One State's Way to Bolster Health Coverage for Poor
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The New York Times
October 24, 2015 Saturday
Late Edition - Final
Federal Officials to Unveil Retooled HealthCare.gov
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 824 words
WASHINGTON -- Starting on Sunday, health care consumers shopping on the Affordable Care Act's federal website, HealthCare.gov, can see the cost and benefits of insurance plans for 2016, the Obama administration said Friday. But they will have to wait a little longer for new features that will allow them to search for plans that cover specific doctors and prescription drugs, administration officials said.
''The consumer experience this year will be easier and faster,'' said Andrew M. Slavitt, the acting administrator of the Centers for Medicare and Medicaid Services, unveiling a website that has been overhauled and improved. ''The response time will be 40 percent faster than last year.''
Administration officials gave journalists a preview of the new website on Friday. Consumers can begin ''window shopping'' for health plan options on Sunday. Actual purchasing of plans begins Nov. 1, the first day of open enrollment.
The website, the main entry point for people seeking insurance in 38 states served by the federal exchange, includes three major new features.
One, which will be ready on Sunday, allows consumers to see an estimate of total yearly costs for each health plan, based on factors like their age, sex, income, ZIP code and how much health care they expect to use.
A second feature will allow people to enter the names of doctors and hospitals and get back a list of health plans that cover those providers. In the last two years, consumers had to visit the website of each insurer to see which doctors and hospitals were in its network, a task that could be laborious and time-consuming.
A third new feature will allow people to find health plans that cover their prescription drugs.
Kevin J. Counihan, the chief executive of the federal insurance marketplace, could not say when the doctor and drug search tools would be available, beyond promising that it would be soon. The government and insurers are still testing the tools.
Insurers were supposed to provide the government with data on their doctors, hospitals and drugs by Oct. 1, but much of the information has not been submitted in the proper format or checked for accuracy, officials said.
''In an ideal world, we would have gotten 100 percent of the data and have it validated, and we would be ready to go right this second,'' Lori Lodes, a spokeswoman at the Centers for Medicare and Medicaid Services, said Friday. ''But we have a little over half of the data validated, and that needs to be better.''
Mr. Counihan added: ''This is new technology for everybody. We don't want to introduce anything that is not fully working.''
Federal officials said it would be a challenge to sign up more people for coverage through the exchanges because many of those with the greatest need and desire for insurance already have it.
Sylvia Mathews Burwell, the secretary of health and human services, said last week that she expected 10 million people to be enrolled through the federal and state exchanges at the end of next year. Some outside experts described that as a surprisingly modest goal. About 9.9 million people were enrolled through the exchanges at the end of June.
The open enrollment period ends Jan. 31. The administration is aiming to sign up more than one of every four uninsured consumers eligible for coverage through the marketplaces. People who already have coverage can renew it or pick different plans.
The government and insurers have encountered several difficulties trying to create a comprehensive database listing the thousands of doctors, hospitals and drugs covered by health plans around the country.
Federal officials said, for example, that a health plan might cover the services of a doctor practicing at one location, but not the services of the same doctor practicing at a different location.
In response to a consumer's search request, for example, the new website will indicate whether a doctor is ''covered'' or ''not covered'' by a particular health plan. In testing this feature of the website, insurers sometimes found that the information was inaccurate.
Such inaccuracies could have serious consequences for consumers, who might pick a health plan in the belief that it included their doctor, only to find that they were responsible for most or all of the costs because the doctor was not in the network of that health plan.
Another technical difficulty results from the fact that hospital systems in many states have been buying doctors' practices in recent years, turning the doctors into hospital employees. In some cases, insurers said, the names of these doctors do not show up in provider directories, so consumers could be misled.
Federal officials said they hoped to have problems with the provider-search feature of the website fixed within a week.
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URL: http://www.nytimes.com/2015/10/24/us/politics/health-laws-revamped-site-healthcaregov-to-debut-on-sunday.html
LOAD-DATE: October 25, 2015
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GRAPHIC: PHOTO: A counselor helping a man in Houston buy insurance under the Affordable Care Act. On Sunday, a revamped health coverage website will debut. (PHOTOGRAPH BY MICHAEL STRAVATO FOR THE NEW YORK TIMES)
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The New York Times
January 25, 2017 Wednesday
Late Edition - Final
Heated Hearing for Health Nominee Is Unlikely to Derail His Confirmation
BYLINE: By ROBERT PEAR and THOMAS KAPLAN; Emmarie Huetteman contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1312 words
WASHINGTON -- In a heated confirmation hearing that focused on ethical issues, President Trump's nominee for secretary of health and human services, Representative Tom Price, defended his trading of medical and pharmaceutical stocks on Tuesday, saying, ''Everything that I did was ethical, aboveboard, legal and transparent.''
Democrats accused Mr. Price of a potential conflict of interest at a hearing of the Senate Finance Committee, saying he held more than $100,000 in stock in companies that could have benefited from legislation he promoted. Mr. Price, a Georgia Republican, denied any wrongdoing.
He also avoided being pinned down on the future of the Affordable Care Act, Medicare and Medicaid, programs that insure more than 100 million people.
While Mr. Price faced vigorous questioning from Democrats, he and other cabinet nominees have benefited from solid support among Republicans, who hold a 52-48 majority in the Senate.
But some nominees had bipartisan support. By a vote of 96 to 4, the Senate approved the nomination of Gov. Nikki R. Haley of South Carolina to be ambassador to the United Nations.
Senator Benjamin L. Cardin of Maryland, the senior Democrat on the Foreign Relations Committee, praised Ms. Haley for ''moral clarity,'' noting that she had declared that the Russians were guilty of war crimes in bombing the Syrian city of Aleppo -- an assertion that Rex W. Tillerson, Mr. Trump's choice for secretary of state, declined to make.
Senate committees endorsed other nominations on Tuesday: Elaine L. Chao for transportation secretary, Wilbur L. Ross for commerce secretary and Ben Carson for secretary of housing and urban development.
Linda McMahon, selected by Mr. Trump to lead the Small Business Administration, also sailed through her confirmation hearing. She was introduced and endorsed by the senators from her home state, Connecticut: Richard Blumenthal and Christopher S. Murphy, both Democrats.
The endorsements were notable because Ms. McMahon ran for the Senate and was defeated by Mr. Blumenthal in 2010 and Mr. Murphy in 2012.
Even as some nominees advanced, Republicans were becoming frustrated and angry. They said Democrats were delaying and prolonging the reviews, raising procedural objections without changing the likely outcome.
Senator John Cornyn of Texas, the No. 2 Senate Republican, accused the Democrats of ''obstruction and foot-dragging'' and said they were ''attempting to litigate or re-litigate the election.'' Senator John Thune, Republican of South Dakota, said: ''The president won an election. He deserves to get his people in place.''
The hard feelings felt to some like payback. Democrats noted that Republicans had stalled many of President Barack Obama's picks and refused to act on his nomination of Judge Merrick B. Garland to the Supreme Court.
In the Senate Committee on Energy and Natural Resources, Democrats held up confirmation votes for two nominees: Representative Ryan Zinke of Montana for interior secretary and former Gov. Rick Perry of Texas for energy secretary. The Democrats said they had unanswered questions about important research programs at the Energy Department.
Democrats on the Finance Committee put Mr. Price through three and a half hours of grueling interrogation. But they appeared unlikely to block his confirmation unless other damaging information comes to light.
''We've always known where the votes are,'' said Senator Ron Wyden of Oregon, the senior Democrat on the committee. The panel could vote next week on whether to recommend confirmation, with its Republican majority strongly supporting Mr. Price.
Mr. Price was asked about an executive order issued by Mr. Trump on Friday that tells federal officials to provide relief from costs, penalties and regulatory burdens imposed on consumers, insurers and health care providers by the Affordable Care Act.
Mr. Wyden asked Mr. Price if he would promise that no one would be worse off and no one would lose coverage as a result of the order. Mr. Price declined to provide an explicit assurance. He promised instead to work with Congress to ''make certain that we have the highest-quality health care and that every single American has access to affordable coverage.''
Senator Maria Cantwell, Democrat of Washington, said the administration appeared to be planning a ''war on Medicaid.'' Mr. Price rejected that description, saying he wanted to give states more control over Medicaid, which covers more than 70 million low-income people.
Senator Dean Heller, Republican of Nevada, asked Mr. Price for a commitment that any replacement for the Affordable Care Act would allow states to continue the expansion of Medicaid eligibility already approved by Nevada and 30 other states.
Mr. Price deferred to Congress, saying, ''This is a policy question that needs to be worked out through both the House and the Senate.'' He said he wanted to ensure that people ''who are currently covered through Medicaid expansion either retain that coverage or in some way have coverage through a different vehicle.''
In any event, he said, ''every single individual ought to be able to have access to coverage.''
He added that many people had Medicaid coverage but could not find doctors to treat them.
''One out of three physicians who ought to be able to see Medicaid patients in this nation do not take any Medicaid patients'' because of low reimbursement rates, burdensome regulations or the ''hassle factor,'' Mr. Price said.
Mr. Price has led efforts to repeal the Affordable Care Act. He refused on Tuesday to say whether he would fight to preserve the expanded coverage of prescription drugs provided to Medicare beneficiaries under the law. Rather, he said, ''it is imperative we provide the greatest amount of opportunity for individual seniors to be able to gain access to the drugs that they need.''
That answer did not satisfy Senator Bill Nelson, Democrat of Florida, which is home to more than four million Medicare beneficiaries. ''If I gave them that answer,'' Mr. Nelson said, ''I would get run out of the room with a group of senior citizens.''
Mr. Price also declined to say how he would carry out Mr. Trump's promise to drive down prescription drug prices. Mr. Trump has said he will do so by negotiating with drug manufacturers and by requiring them to bid for government business.
A background investigation of Mr. Price found that he had understated the value of his investments in an Australian pharmaceutical company and claimed income tax deductions that he could not substantiate. The findings emerged from a review of his tax returns and other official documents by Finance Committee staff members from both parties.
In a questionnaire in December, the staff said, Mr. Price understated the value of 400,613 shares of the Australian company, Innate Immunotherapeutics, that he purchased in August through ''a private placement offering.''
''It's hard to see how this can be anything but a conflict of interest and an abuse of his position,'' Mr. Wyden said. But Mr. Price said that he did not have any ''nonpublic information'' about the company. And the committee chairman, Senator Orrin G. Hatch, Republican of Utah, said the Democrats' attacks on Mr. Price's ethics were ''specious and distorted.''
The committee staff added that Mr. Price had taken ''improper deductions on his 2016 tax returns'' for the depreciation of land associated with condominiums he owns in Washington and Nashville. He and his wife, both physicians, also claimed ''miscellaneous employment deductions totaling $19,034'' for expenses in 2013, 2014 and 2015, the staff said. But ''proper documentation could not be located,'' so his returns will be amended.
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URL: http://www.nytimes.com/2017/01/24/us/politics/tom-price-nominee-secretary-of-health-and-human-services.html
LOAD-DATE: January 25, 2017
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GRAPHIC: PHOTO: Representative Tom Price testified before the Senate Finance Committee on Tuesday in a hearing focused on ethical issues. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES)
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(Ross Douthat)
November 21, 2013 Thursday
Obamacare and the Medical Cartel
BYLINE: ROSS DOUTHAT
SECTION: OPINION
LENGTH: 851 words
HIGHLIGHT: Just because doctors are overpaid doesn’t mean that wage and price controls are a good idea.
Matt Yglesias has kicked up a mini-commotion with a piece hailing any potential Obamacare-driven cuts to physician income as basically exactly the medicine our overpriced medical system needs. Here's his argument:
... American doctors get paid more than doctors in any other country. Given how much of health care is financed either directly (Medicare, Medicaid, Veterans Affairs, public-sector workers) or indirectly (tax subsidy for employer-provided insurance) by the federal government, it's natural to make restraining doctors' income part of any program for making health care more affordable. So when you read stories about doctors whining that Affordable Care Act exchange plans don't pay them enough, please throw up a little in your mouth and proceed to ignore the doctors' complaints. The only practical reason to worry about low compensation for doctors in the ACA exchanges is it may cause them to boycott exchange patients. If that happens, the solution is to reduce doctors' payment rates elsewhere in the system. If we ever reach the point where American doctors have been squeezed so badly that they start fleeing north of the border to get higher pay in Canada, then we've squeezed too hard. Until that happens, forget about it.
... What we really ought to be doing is working to further pressure the incomes of doctors through supply-side reforms. That means letting nurse practitioners treat patients without kicking a slice upstairs to an M.D., letting more doctors immigrate to the United States, and opening more medical schools. Common sense says that since the population both grows and ages over time, there should be more people admitted to medical school today than were 30 years ago. But that's not the case. Instead we produce roughly the same number of new doctors, admissions standards have gotten tougher, and doctors have become scarcer.
You'll note a slight difference in both tone and substance between the first paragraph (where Yglesias sounds like, shall we say, a particularly hepped-up MSNBC host ranting against the selfish Republican-voting rich) and the second paragraph (where he sounds more like Milton Friedman, who once described of the American Medical Association as "the strongest trade union in the United States"). For a heterodox liberal writing mostly for mostly partisan audience, it's a savvy way to structure an argument: Come for the defense of the Affordable Care Act (and to watch the predictable outrage from conservatives who like their doctor and mistakenly imagine that ours is a free market in medical services), and stay for a little unconventional, even right-of-center wisdom about the problem with government-subsidized cartels and the uses of deregulation.
But I'm not sure the combination holds together analytically. If supply-side reforms are the real answer to the problem of inflated medical salaries (and I'm pretty sure they are) then should we be praising a policy, Obamacare, that tries to restrain salaries and payments by fiat instead? Jokes about doctors fleeing to Canada notwithstanding, unless Democrats have a plan to completely nationalize health care there's still going to be somewhere else for the best physicians to go: They can stop participating in public plans, stop participating in exchange plans, and and then eventually stop taking insurance entirely and just opt to serve an exclusively upper middle class clientele via concierge medicine. And if you combine this opting-opt out at the top of the talent distribution with the fact that Obamacare will presumably dramatically expand the demand for physician services for the newly-subsidized, you have a recipe for basically importing Medicaid's existing access and quality-of-care problems into the rest of the publicly-subsidized insurance market.
Would this shift also restrain doctor salaries (or the average doctor's salary, at least), and with them, medical costs? Well, yes, to some extent it might - and so in a sense, this is just taking us back into the ideologically-charged debate over whether "Medicaid for all" would be a good idea or not. But it's noteworthy that Yglesias's nominally liberal and pro-Obamacare piece actually suggests a very different prescription (and yes, admittedly, one that many A.M.A.-funded Republicans would oppose) than the Medicaid-for-most model that Obamacare might end up delivering. He's basically acknowledging that what we actually need is medical-industry deregulation to counteract the market-distorting impact of a heavily-subsidized medical cartel, but then still embracing as a second-best option a policy that answers that cartel with wage and price controls instead, essentially piling a new set of distortions on top of the old set in the hopes that they cancel each other out. And given his own analysis of the underlying dynamics, I think it's reasonable to doubt whether that second-best solution is really much of a solution at all.
Why Not Medicaid For All?
The Illusions of Employer-Based Health Insurance
Does Individual Insurance Work?
Different Kinds of Health Care Disruption
Was Rate Shock Necessary?
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July 5, 2012 Thursday
TimesCast Politics: Romney and the Mandate
BYLINE: THE NEW YORK TIMES
SECTION: US; politics
LENGTH: 79 words
HIGHLIGHT: Michael Barbaro on the Republican reaction to a shift in position from the Romney campaign, Nate Silver looks ahead to Friday's jobs report and Robert Draper previews his Sunday Magazine profile of the pro-Obama 'super PAC.'
Michael Barbaro on the Republican reaction to a shift in position from the Romney campaign, Nate Silver looks ahead to Friday's jobs report and Robert Draper previews his Sunday Magazine profile of the pro-Obama 'super PAC.'
In Florida, Obama Assails Republicans Over Immigration Policy
Supreme Court Could Pose New Challenge for Romney on Immigration
Campaigns Use Opponent's Words, and Cry Foul
The Caucus Click: The Week in Pictures
Romney Campaigns at Failed Solyndra Factory
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The New York Times
December 27, 2016 Tuesday
Late Edition - Final
Doctors in Rift Over Nominee to Health Post
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1626 words
WASHINGTON -- When President-elect Donald J. Trump chose Representative Tom Price of Georgia to be his health and human services secretary, the American Medical Association swiftly endorsed the selection of one of its own, an orthopedic surgeon who has championed the role of physicians throughout his legislative career.
Then the larger world of doctors and nurses weighed in on the beliefs and record of Mr. Price, a suburban Atlanta Republican -- and the split among caregivers, especially doctors, quickly grew sharp.
''The A.M.A. does not speak for us,'' says a petition signed by more than 5,000 doctors.
Mr. Trump and a Republican-held Congress are considering some of the biggest changes to the American health care system in generations: not only the repeal of the Affordable Care Act, which is providing insurance to some 20 million people, but also the transformation of Medicare, for older Americans, and Medicaid, for low-income people. Mr. Price has favored those changes.
Seven years ago, the A.M.A.'s support helped lift President Obama's health care proposals toward passage, and the group has backed the law, with some reservations, since its adoption in 2010. But as Republicans push for its dismantlement, deep disagreements within the A.M.A., which has long wielded tremendous power in Washington, could lessen its influence.
The concerns voiced by dissident doctors do not appear to imperil Senate confirmation of Mr. Price, but they do ensure that his confirmation hearings next month will be as contentious as any held for a Trump nominee, featuring a full public examination of the new president's proposed health policies.
''Doctors are divided big time,'' said Dr. Carl G. Streed Jr., a primary care doctor at Brigham and Women's Hospital in Boston and a member of the A.M.A. house of delegates, the organization's principal policy-making body.
The controversy began soon after Mr. Trump announced on Nov. 29 that he had chosen Mr. Price to head the Department of Health and Human Services, which controls Medicare, Medicaid, the Affordable Care Act's federal health insurance exchange, the National Institutes of Health, the Food and Drug Administration and the Centers for Disease Control and Prevention.
Within hours, the A.M.A. -- the nation's largest medical advocacy group, which has nearly 235,000 members and calls itself ''the voice of the medical profession'' -- issued a statement saying it ''strongly supports'' the selection.
It noted Mr. Price's experience as a doctor, a state legislator and a member of Congress. It praised, in particular, his support for ''patient choice and market-based solutions'' and his efforts to reduce ''excessive regulatory burdens'' on doctors.
The enthusiasm was understandable at one level: Mr. Price has been a member of the A.M.A. house of delegates since 2005 and was an alternate delegate for a decade before that, according to the A.M.A. and the Medical Association of Georgia.
''For those who are attacking Dr. Price, I have to ask whom you would rather have at the helm of H.H.S. -- a career bureaucrat? A former governor who views doctors as a cost center to be controlled?'' said Dr. Robert E. Hertzka of San Diego, an anesthesiologist and former president of the California Medical Association. ''Tom Price may turn out to be the best friend that physicians and patients have ever had in that role.''
Many doctors are not willing to take that chance. More than 750 people who identify themselves as members of the A.M.A. signed a letter to the association's board objecting to the endorsement.
The ''unqualified support'' for Mr. Price is inappropriate, the letter says, because he has been ''a strong opponent of so much of our clearly delineated A.M.A. policy'' on issues like the Affordable Care Act, contraception and gay rights. Some doctors also said patients could be hurt by major changes in Medicare and Medicaid that Mr. Price, along with other House Republicans, has advocated.
Dr. Andrea S. Christopher, 32, an internal medicine doctor at the veterans hospital in Boise, Idaho, said she had decided not to renew her A.M.A. membership over the endorsement, which she called especially upsetting to her generation of physicians. ''Dr. Price has been an outspoken opponent of the Affordable Care Act, which has done so much to address the needs of our most vulnerable patients and reduced the uninsured rate to the lowest level on record,'' Dr. Christopher said.
Dr. Kristin M. Huntoon, a 37-year-old neurosurgery resident at Ohio State University in Columbus, said the group's support for Mr. Price had increased the chances that the Affordable Care Act would be dismantled -- and that has put her patients at risk.
Ohio has extended Medicaid coverage to more than 600,000 people under the federal health care law. If that expansion is reversed, Dr. Huntoon said, some patients will not receive imaging or treatment at an early stage of their disease, and they are more likely to arrive when tumors have spread to the brain. ''At that stage,'' she said, ''there's often nothing I can do for the patient.''
Physicians have long been a focus of Mr. Price's legislative efforts. He led the push to fix widely recognized flaws in Medicare's formula for paying doctors and supported changes in malpractice laws that could make it easier for doctors to defend themselves. He supported changes in Medicare that would allow doctors to get around fee limits by signing contracts with patients. He has also backed changes in antitrust law that would enhance doctors' bargaining power in negotiations with insurance companies.
''Pocketbook issues -- the economic well-being of physicians -- may well be a factor contributing to the A.M.A.'s endorsement,'' said Dr. Manan Trivedi, a former Democratic candidate for Congress, who is the president of the National Physicians Alliance, a group of 10,000 doctors that opposes Mr. Price's confirmation.
Dr. Patrice A. Harris, the chairwoman of the A.M.A., strongly defended the group's actions and suggested that Mr. Price could surprise critics as Dr. C. Everett Koop did in the 1980s, when he was surgeon general under President Ronald Reagan. Liberal politicians and women's groups initially criticized Dr. Koop because of his opposition to abortion, but when he stepped down after more than seven years in office, he was widely praised for his role in fighting AIDS and discouraging the use of tobacco.
''We do realize that there is a diversity of opinion on Dr. Price,'' Dr. Harris said in an interview. ''We respect that diversity. We take the concerns that have been expressed by some of our members and by physicians in general seriously.
''Our support for Dr. Price is based on our history with him, his extensive involvement with A.M.A.,'' she added. ''He's a longtime member, he's a delegate. For us, he has always been accessible. He listens, and he really knows how policies impact the delivery of care and the physician-patient relationship.''
Phillip J. Blando, a spokesman for the Trump transition team, said Mr. Price had been endorsed by many medical groups and was ''uniquely prepared'' for the job. ''If confirmed,'' he said, ''Dr. Price will work to restore the patient-doctor relationship and clamp down on government overreach.''
Mr. Price has introduced legislation to repeal Mr. Obama's health law, including its expansion of Medicaid and subsidies for the purchase of private insurance. He advocates tax credits to help people buy insurance, greater use of individual health savings accounts and state-run ''high-risk pools'' for people with pre-existing conditions who might otherwise have difficulty finding affordable coverage.
As a member of the House Budget Committee, and then its chairman, he has supported proposals to shift Medicare away from its open-ended commitment to pay for medical services and toward a fixed government contribution for each beneficiary, which could be used for either private insurance or traditional Medicare. Such proposals could increase costs for some beneficiaries or limit the amount of care they receive, health policy experts say.
Mr. Price has also backed turning Medicaid into block grants to state governments. Critics say that states would probably respond by restricting eligibility, cutting Medicaid benefits or reducing payments to health care providers.
In leading efforts to repeal the president's health law, he is pursuing a goal in opposition to the policies of the A.M.A. In a 2010 letter to congressional leaders, Dr. J. James Rohack, who was then president of the A.M.A., said the law took ''an important step toward improving the health of the American people,'' by ''extending coverage to the vast majority of the uninsured'' and ''improving competition and choice in the insurance marketplace.''
Dr. Samantha G. Harrington, a doctor at Cambridge Hospital in Massachusetts, said she had canceled her A.M.A. membership because she found its endorsement of Mr. Price ''embarrassing and shameful.''
Dr. Thomas M. Gellhaus, president of the American Congress of Obstetricians and Gynecologists, said Mr. Price had ''worked closely with us'' on many issues. But, he said in a recent letter to the congressman, ''some of the bills you supported in Congress would not serve women's health well.''
Mr. Price has supported efforts to restrict abortion and cut off federal funds for Planned Parenthood clinics. If confirmed, Mr. Price would be only the third physician to serve as secretary in the 63-year history of the Health and Human Services Department and its predecessor, the Department of Health, Education and Welfare.
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URL: http://www.nytimes.com/2016/12/26/us/tom-price-hhs-donald-trump-cabinet.html
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GRAPHIC: PHOTO: Senator Mitch McConnell, left, with Representative Tom Price, chosen to lead the Department of Health and Human Services. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES) (A12)
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October 14, 2013 Monday
The International New York Times
Mileposts Remain for Health Law
BYLINE: By ALBERT R. HUNT | BLOOMBERG VIEW
SECTION: Section ; Column 0; Foreign Desk; LETTER FROM WASHINGTON; Pg.
LENGTH: 954 words
WASHINGTON -- The drama surrounding the government shutdown and potential debt default almost obscured the rollout of President Obama's Affordable Care Act. Both champions and critics of the measure should be grateful.
More than eight million Americans tried to log on to federal or state exchanges, despite concerted efforts by conservatives to dissuade them. Software glitches foiled many of these inquiries and undermined supporters' claims that the program was ready for prime time.
The confusion also underscored again that this measure has been the focus of greater partisan rancor than any major U.S. legislation in recent memory. High emotion often distorts reality. The Oct. 1 rollout was interesting, instructive and not all that important. Over the next year or so, there are at least four crucial benchmarks:
Dec. 15: That's when we will know if the computer glitches have been fixed and whether the administration has adequately promoted the law in preparation for Jan. 1, when coverage of the uninsured begins.
Interested customers will come back often. The Massachusetts plan -- a model for Obamacare -- registered an average of three to six inquiries before someone signed up. Young people are patient when awaiting the next iPhone or ''Hunger Games'' movie, but if the exchanges don't eliminate the glitches, some prospective sign-ups will be turned off.
The administration doesn't have its act together. It has enlisted Chris Jennings, a respected expert, as its point man for policy. There's a distance, however, between the White House and the Department of Health and Human Services, and the marketing efforts have been much weaker than some proponents advocated.
Celebrities including Kerry Washington, John Legend, Katy Perry and the Pittsburgh Steelers have promoted the law. But some of the measure's backers are calling for a far more elaborate effort involving rock stars, athletes and lots of white-coated doctors and nurses.
April 1: The Congressional Budget Office estimates that seven million Americans will sign up in the first three months.
Achieving that goal, both sides agree, would be a good marker of early success. Failure would signal major problems. Supporters say more than one-third of the enrollees should be younger people.
A year from now: One bit of very good news is that health care costs have moderated. If that trend holds over the next year, insurance rates, which factor in risks and likely costs, will probably come down.
January 2015: More than half the states aren't participating in a federally funded expansion of Medicaid for poorer citizens; many of these states aren't participating in the exchanges, either. For the most part, these are heavily Republican areas, where anything associated with Mr. Obama is politically lethal.
Ezekiel J. Emanuel, a former top Obama adviser on health care who now is a vice provost at the University of Pennsylvania, said the partisan pressure might subside after the 2014 election. Some of the recalcitrant governors, and some newly elected ones, could change course.
''The money is just too good, and they're going to look at places like California and Oregon and Colorado and see the results are so much better than in their states,'' Mr. Emanuel said.
He acknowledges that his brother Rahm Emanuel, the mayor of Chicago and a former White House chief of staff, fears that this prediction is wrong and that ideology will continue to trump practicality.
The Republican critics are on stronger ground when they reject White House complaints that the Affordable Care Act is a settled issue. No piece of legislation is settled and safe from review, modification or elimination. President Ronald Reagan's tax cuts and President Bill Clinton's welfare overhaul were reshaped multiple times.
Still, it was a politically frivolous and base-pandering act for House Republicans, who have a less than vigorous schedule anyway, to vote 42 times to repeal the health care law, knowing that repeal would be unacceptable to the Senate or the president.
The Republicans offer few serious alternatives, unless they are responding to political pressures. Consider the politically potent makers of medical devices who have used a plethora of flawed contentions to persuade almost all Republicans (and quite a few Democrats) to try to repeal a small tax levied on their products.
At the same time, Republicans haven't permitted corrections to some obvious flaws in the initial Obamacare legislation. Remedies of this kind were passed after Medicare was enacted in 1965.
''Obama is taking executive actions that may produce a lot of litigation,'' said Joseph A. Califano Jr., who was a top adviser to President Lyndon Johnson when Medicare was passed, ''because Republicans won't allow even simple things to be fixed.''
Some of the claims made by these congressional critics are simply disingenuous, like the assertion that people with pre-existing conditions are already allowed to keep their coverage so they don't need Obamacare. That's true of those who have coverage, but for those with illnesses who aren't insured, insurance is difficult to get. Even for those who are covered, there's little to prevent insurance companies from jacking up rates. That will change under Obamacare.
Such benefits, the moderating cost of health care and the surge of interest in the exchanges all augur well for the Affordable Care Act in these early stages. But there's an ominous offset: The political fiascoes with the government shutdown and possible debt default have, as the political right hoped, elevated cynicism about the federal government as a whole. Logic suggests that negative sentiment will also be directed at a huge new federal program like universal health care.
URL: http://www.nytimes.com/2013/10/14/us/mileposts-remain-for-health-care-law.html
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June 28, 2016 Tuesday
The Growing Cost of a Hospital Stay
BYLINE: ANNA NORTH
SECTION: OPINION
LENGTH: 442 words
HIGHLIGHT: Health insurance isn’t necessarily a protection against high hospital bills as insurers pass costs along to patients.
If you have to go to the hospital, health insurance is supposed to cushion the financial blow. But as insurers pass more costs along to patients, hospitalizations are getting more expensive, and checking in can come with a four-figure bill.
A new study, conducted by researchers at the University of Michigan, Ann Arbor and published in JAMA Internal Medicine, looked at how much people with employer-sponsored or individual insurance plans spent on hospital stays between 2009 and 2013. During that period, the average out-of-pocket spending per stay grew by 37 percent, from $738 to $1,013. That's a growth rate of 6.5 percent per year, during a time when overall health care spending grew just 2.9 percent annually.
The researchers also looked at costs for specific conditions and procedures. Average out-of-pocket spending for a hospital stay involving a heart attack went up by 37 percent, from $1,158 to $1,586. Appendicitis patients saw a 40 percent increase, from $1,079 to $1,509.
The average copayment for a hospital stay - a fixed amount paid per visit - actually fell during the study period. But coinsurance - the percentage of costs patients pay themselves - went up by 33 percent, and the amount that hospitalized patients paid toward their deductibles went up by 86 percent.
In 2015, the study's authors note, the average deductible for individual coverage under an employer-sponsored plan was more than $1,300. For plans on the health care exchanges (which began after the study concluded), deductibles can be significantly higher - the median deductible last November was $4,000 in Phoenix and $5,000 in Miami, according to HealthCare.gov.
Some health economists have said high deductibles could help reduce costs by encouraging patients to shop for cheaper care, but a study published earlier this year suggested that people might be reluctant to comparison-shop for health care. And, as Emily Adrion, a research fellow at the University of Michigan's Center for Outcomes and Policy and one of the study's authors, put it, "if you're having a heart attack or you have appendicitis, you don't really have time to shop around."
To help with out-of-pocket spending, the Affordable Care Act provides subsidies for people making up to four times the federal poverty level. But the subsidies aren't available for those with employer-sponsored insurance, the study's authors point out.
Helping the uninsured get coverage is crucial, but simply having insurance isn't a guarantee of affordable care. As Dr. Adrion said, "People can face significant financial risks even if they have some of the more high-quality insurance coverage in this country."
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January 8, 2015 Thursday
The New 'Obamacare' Bill Would Hurt Workers and Increase the Deficit
BYLINE: TERESA TRITCH
SECTION: OPINION
LENGTH: 545 words
HIGHLIGHT: Republicans want to raise the hours-per-week threshold at which employers have to offer health insurance.
Addressing lawmakers on Tuesday after his reelection as House Speaker, John Boehner chalked up partisan and intra-party divisions of the past six years to the "battle of ideas" that "never ends, and frankly never should."
I don't begrudge him his moment to huff and puff.
But the battle-of-ideas frame is going too far. Since 2009, about the only animating idea from congressional Republicans has been to say "no" to whatever President Obama and the Democrats have suggested. Republicans have said "no" even when Democrats re-proposed Republican ideas. As a result, the past six years have not been a battle of ideas so much as a battle to stop ideas dead in their tracks. And when that has failed, as in the case of the Affordable Care Act, Republicans have worked to undo any progress - not for the sake of better ideas, but for the sake of denying the president success.Things will only get worse starting Thursday, when House Republicans are expected to bring to the floor an anti-"Obamacare" bill that is, from start to finish, an exercise in dishonesty.
The health reform law requires employers with at least 50 full time-equivalent employees to offer health insurance to those who work at least 30 hours a week, or pay a penalty. The bill seeks to limit the employer requirement to employees who work at least 40 hours a week. Its supporters, mostly Republicans and a handful of Democrats, are counting on winning over the public with the argument that a 30 hour threshold will cause employers to cut back work hours and that a 40-hour threshold will foster more full time work. But that's wrong .
First, there is little evidence that the law, as is, is causing employers to cut hours. Worse, a higher threshold would actually increase the number of employees at risk of having their hours cut.
Here's why: Under the law's 30-hour a week threshold, the only workers at any real risk of having their hours cut are those who typically work right around 30 hours a week - about 7 percent of the workforce. If the threshold were raised to 40 hours, as the bill proposes, the workers at risk of having their hours cut would be those who typically work right around 40 hours a week - nearly half of the workforce. After all, it would be relatively easy to cut someone back from 40 to 38 hours, but quite unlikely to cut from 40 to 29 hours. So in purporting to solve what is basically a non-problem, the bill could actually create a real problem.
The actual aim of the bill is not to protect employees from cuts to their work hours. The aim is to undermine health reform and curry favor with corporate constituents. In contrast to the 30 hour threshold in current law, the bill's proposed 40 hour threshold would let businesses deny insurance to employees who work between 30 and 39 hours a week, without paying a penalty. Over 10 years, that would shift increase the budget deficit by shifting some $46 billion of the cost of insuring those employees onto taxpayers, according to the Congressional Budget Office.
Congressional Republicans are fighting a battle all right, but it is not a battle of ideas. It is a battle against Democrats over everything that Mr. Obama is for. It is, in short, the same battle they were fighting before they controlled both houses of Congress.
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November 26, 2014 Wednesday
Late Edition - Final
Schumer Criticizes Timing of Affordable Care Act
BYLINE: By JEREMY W. PETERS
SECTION: Section A; Column 0; National Desk; NATIONAL BRIEFING | WASHINGTON; Pg. 19
LENGTH: 135 words
Senator Charles E. Schumer, Democrat of New York, said Tuesday that it was a political mistake to pass the Affordable Care Act in 2010 because voters were looking instead for relief from the recession. Mr. Schumer, in remarks at the National Press Club, said Democrats should have built on the stimulus package that Congress passed to create programs to help middle-class Americans. ''Unfortunately, Democrats blew the opportunity the American people gave them,'' Mr. Schumer said, according to his prepared remarks. ''We took their mandate and put all of our focus on the wrong problem -- health care reform.'' Republicans, he added, were able to exploit a sense among voters that Democrats were interested in creating new government programs that did not benefit them, helping to spawn the Tea Party movement.
URL: http://www.nytimes.com/2014/11/26/us/schumer-criticizes-timing-of-affordable-care-act.html
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(The Loyal Opposition)
April 27, 2012 Friday
Healthcare: What Might Have Been
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 431 words
HIGHLIGHT: Anthony Weiner wanted to gradually expand Medicare. John Tanner wanted to break the ACA down into several parts.
Long before the sexting scandal that ended his career, Rep. Anthony Weiner advised the president on how to pass healthcare reform. Robert Draper reports in his new book, "Do Not Ask What Good We Do," that in September of 2009 Mr. Weiner told the president, "I think you're looking at this entirely the wrong way. You need to simplify it. Just say that what we're doing is gradually expanding Medicare."
That was code for a single-payer system, which the president insisted could never pass. But Mr. Weiner was undeterred: "You only have votes for something when you go out and fight for them."
It's impossible to say what might have happened if Mr. Obama had listened to Mr. Weiner, but with hindsight it's obvious that his strategy had certain advantages. By framing the Affordable Care Act as an expansion of an already popular program-instead of as a bold new experiment-the Democrats could have better defended themselves against right-wing attacks. The ludicrous "keep government out of my Medicare" meme might never have taken off. Maybe we'd have ended up with the single-payer system liberals wanted instead of the Heritage Foundation-inspired individual mandate, which might not even survive Supreme Court review.
Mr. Weiner wasn't the only congressman to pitch an alternative approach. According to Mr. Draper, John Tanner, a Blue Dog Democrat, told House Speaker Nancy Pelosi that she should "break the bill down:"
Have a bill that covers pre-existing conditions. Pass that-or make the Republicans vote against it-and then move onto another part. But you do this omnibus approach, they won't know what the hell's in it. And they'll keep yelling at it.
Mr. Tanner was right about the yelling, and maybe about everything else. According to the Kaiser Family Foundation, the "component parts" of the ACA have been "consistently popular" over the past two years with one "glaring exception:" Only 32 percent favor the individual mandate. It stands to reason that it's discomfort with the mandate, and that alone, that drives a plurality of Americans to say Congress should repeal the ACA (about 38 percent, depending on the poll, with about 20 percent wanting to leave it as is, and 33 percent favoring expansion). Under Mr. Tanner's scheme, the Democrats could have campaigned on the "component parts," described the mandate as a payment mechanism, and defied the opposition to come up with a viable alternative to it.
Romney's Health Care Plan
Opinion Report: Crack and Cocaine
Opinion Report: Santorum Drops Out
The President Fumbles the Court Issue
Opinion Report: America's No. 1 Foe
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March 26, 2014 Wednesday
Facts & Figures: Clueless on the 'Obamacare' Deadline
SECTION: OPINION
LENGTH: 198 words
HIGHLIGHT: The Obama administration plans to extend the sign-up deadline, which many people don’t seem to even know about.
The Obama administration said yesterday that it would treat the March 31 deadline for enrolling in a health plan somewhat flexibility. Consumers who begin to apply by March 31 will have until mid-April to finish.
Relatedly, according to the Kaiser Health Tracking Poll for March, "substantial shares" of the uninsured population don't realize that the deadline to sign up for health insurance is fast approaching.
"As the clock ticks down on open enrollment for new coverage options under the Affordable Care Act (ACA), the latest Kaiser Health Tracking Poll finds that six in ten of the uninsured are unaware of the March 31 deadline to sign up for coverage. When reminded of the deadline and the fine for not getting covered, half of those who lack coverage as of mid-March say they plan to remain uninsured. Meanwhile, four in ten of the uninsured are still unaware of the law's subsidies to help lower-income Americans purchase coverage, and half don't know about the law's expansion of Medicaid."
The Women on the Sidelines of the Hobby Lobby Case
No, 'Obamacare' Isn't Killing 2 Million Jobs
What's Behind the Declining Abortion Rate?
Looking Callous at the SOTU
Mike Huckabee's War for Women
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The New York Times Blogs
(In Practice)
November 21, 2013 Thursday
Maine Hires Firm to Study Medicaid System, to Democrats' Ire
BYLINE: Jess Bidgood
SECTION: US
LENGTH: 727 words
HIGHLIGHT: Officials in Maine have hired a consulting firm — one with Republican ties and a history of suggesting cost cuts — to study the state’s Medicaid system, to include evaluating the cost of expanding the program under President Obama’s Affordable Care Act.
Officials in Maine have hired a consulting firm to study the state's Medicaid system, to include evaluating the cost of expanding the program under President Obama's Affordable Care Act, a move Gov. Paul R. LePage has in the past rejected.
The contract was given to the Alexander Group, whose president, Gary Alexander, is a former secretary of Public Welfare in Pennsylvania under Gov. Tom Corbett, a Republican. During his tenure, from 2011 to 2013, Mr. Alexander proposed cuts to public assistance programs and was opposed to expanding Medicaid.
While Mr. Alexander has been praised by conservatives for his focus on welfare fraud and cost-cutting in public assistance programs, Maine Democrats have raised concerns that his evaluation is intended to bolster efforts by Mr. LePage, a Republican, to trim benefits.
The Alexander Group conducted a review of Arkansas' Medicaid and welfare system this year that proposed a variety of cost-saving measures. After that review was completed, the Obama administration approved a hybrid Medicaid expansion plan proposed by the state, which called for using taxpayer dollars to buy private insurance for new Medicaid enrollees. Pennsylvania and Tennessee are now proposing similar plans, but have yet to receive federal approval.
The LePage administration has previously said it was interested in the Arkansas plan.
"Governor LePage is aware of and understands the details of these alternatives, which have been developed in other states," said Adrienne Bennett, the governor's press secretary, in a press statement first released to The Portland Press Herald last month.
"A one-size-fits-all approach is not acceptable and we hope the Obama administration continues to be open to creative solutions that states develop for themselves," Ms. Bennett said.
A release issued on Tuesday by the state department of health and human services said the Alexander Group would assess the cost of expansion, and consider "potential areas of flexibility for the state, which may include requests for additional flexibility from the federal government to manage MaineCare by state rules instead of federal regulations."
Some Democrats in the state immediately raised concerns about the evaluation.
"The philosophy of the consultants, I believe, is merely an effort on the part of the administration to bolster their own philosophy about the human service budget in the State of Maine," said state Rep. Richard Farnsworth, a Democrat who is chairman of his chamber's Health and Human Services Committee.
Critics cited the record of Mr. Alexander, who, while running Pennsylvania's welfare department, established an asset test for food stamp eligibility and cut about 130,000 people from state welfare rolls in a five-month period, according to The Philadelphia Inquirer. Critics also objected to the cost of the contract, $925,000.
"It's really just another gimmick to deny tens of thousands of Mainers health care," said state Representative Jeff. McCabe, a Democrat who represents Skowhegan and is the House's assistant majority leader. "To hire someone that has a track record of just cutting services and privatization - we don't really see that as objective."
Mr. LePage twice vetoed bills passed by the Democrat-controlled Legislature in May and June that would have expanded Maine's Medicaid program under the Affordable Care Act. And he has sought to cut tens of thousands of people from the state's existing Medicaid rolls.
The Alexander Group will also review of the state's welfare system, including its "welfare-to-work" program and its procedures for ensuring that welfare recipients are actually eligible.
"They are providing an analysis and an array of recommendations to the state, that must be evaluated against the governor's priorities to support the most vulnerable in our state," said Mary Mayhew, the commissioner for Maine's Department of Health and Human Services.
Ms. Mayhew said Mr. LePage's position on Medicaid expansion had not changed. "Expansion can only be considered," she said, "once we have identified the ability and the resources to support those core priorities."
White House to Tweak Tax-Penalty Deadline
Programmers Find New Way to Navigate Health Plans
Wisconsin Governor Seeks to Extend Medicaid
Sebelius Finds a Friendly Crowd in Boston
Readers Ask About Subsidies and Other Health Care Law Provisions
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March 25, 2014 Tuesday
The Women on the Sidelines of the Hobby Lobby Case
SECTION: OPINION
LENGTH: 687 words
HIGHLIGHT: Business owners aren’t the only people who will be affected by the Supreme Court’s take on the contraceptive mandate.
Most of the news coverage of the highly-anticipated contraceptive-mandate cases - which came before the Supreme Court on Tuesday morning - has focused on the idea of religious liberty, and to what degree a for-profit corporation can exercise that liberty like a real human person.
But the real human persons at the center of the case - specifically, the women whose access to contraception is at stake - were notably absent from much of the conversation in the court.
The case (actually two cases consolidated into one) arose after several businesses sued the federal government over the Affordable Care Act's requirement that they either provide their employees with comprehensive health insurance, which includes coverage for contraception, or pay a tax.
The businesses' owners are opposed for religious reasons to any contraceptive method that acts after an embryo has formed. Since some of the methods approved under the health-care law can work in that way, the owners charged that the government was violating their right to the free exercise of religion.
At oral argument, there were plenty of questions over what precise legal standards to apply in the case; how far the plaintiffs' logic extended (would it allow corporations to refuse to cover, say, vaccinations or blood transfusions?); and what would be the cost of the various choices available to the companies.
More than half an hour of argument passed before Justice Anthony Kennedy, playing his familiar role somewhere between the liberal and conservative blocs on the court, brought the actual women into the picture. "How would you suggest that we think about the position and the rights of the employees?" Justice Kennedy asked Paul Clement, the attorney for the corporate plaintiffs. "The employee may not agree with these religious beliefs of the employer. Does the religious beliefs just trump? Is that the way it works?"
Until then, you might have thought that the only human beings who would be affected by the court's decision were the owners of the companies themselves: Hobby Lobby Stores, Inc., an Oklahoma-based arts-and-crafts chain owned by evangelical Christians, and Conestoga Wood Specialties Corp., a Mennonite cabinet manufacturer from Pennsylvania.
But Hobby Lobby alone has 13,000 employees, a significant portion of whom are women, or men with female partners who share their insurance. It is safe to assume that many if not most of them have used contraception. And contrary to Justice Antonin Scalia's dismissive suggestion that cost isn't a factor ("That's not terribly expensive stuff, is it?" he said at one point) the four methods at issue in the Hobby Lobby cases, such as IUDs, are among the most effective - and expensive. According to an amicus brief filed by reproductive-health experts, one third of American women say they would change their method of contraception if cost weren't an issue.
In other words, Hobby Lobby's decision not to provide insurance coverage could make it harder for its female employees to obtain basic health services now freely available to other women throughout the country.
Of course, as Justice Kennedy knew when he asked about employee rights, any claim of religious liberty must be considered in the context of the possible burden that liberty imposes on other citizens. Solicitor General Donald Verrilli, who argued the case on behalf of the government, tried to make this point the centerpiece of his case from his opening words.
"Limitations which of necessity bound religious freedom begin to operate whenever activities begin to affect or collide with the liberties of others or of the public," Mr. Verrilli said, quoting Justice Robert Jackson from a 1944 case.
Mr. Verrilli argued that the employees' right to a legally guaranteed health benefit was "left on the sidelines" by the plaintiffs.
Despite his best efforts, for a good part of the morning it was left on the sidelines by the Supreme Court justices as well.
What's Behind the Declining Abortion Rate?
Mike Huckabee's War for Women
Trouble for the Contraception Mandate
Rush Limbaugh Needn't Worry
No, 'Obamacare' Isn't Killing 2 Million Jobs
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May 11, 2016 Wednesday
Late Edition - Final
Clinton Suggests Giving Medicare a Buy-In Option
BYLINE: By ALAN RAPPEPORT and MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1100 words
For months during the Democratic presidential nominating contest, Hillary Clinton has resisted calls from Senator Bernie Sanders to back a single-payer health system, arguing that the fight for government-run health care was a wrenching legislative battle that had already been lost.
But as she tries to clinch the nomination, Mrs. Clinton is moving to the left on health care and this week took a significant step in her opponent's direction, suggesting she would like to give people the option to buy into Medicare.
''I'm also in favor of what's called the public option, so that people can buy into Medicare at a certain age,'' Mrs. Clinton said on Monday at a campaign event in Virginia.
Mr. Sanders calls his single-payer health care plan ''Medicare for all.'' What Mrs. Clinton proposed was a sort of Medicare for more.
The Medicare program covers Americans once they reach 65. Beneficiaries pay premiums to help cover the cost of their coverage, but the government pays the bulk of the bill. Mrs. Clinton's suggestion was that perhaps younger Americans, ''people 55 or 50 and up,'' could voluntarily pay to join the program.
She made the remarks as she continues to face a determined challenge on the left from Mr. Sanders, forcing her to essentially fight a two-front war as she seeks to turn her attention to Donald J. Trump and the general election. While Mr. Sanders trails by a substantial number of delegates, his effect continues to be felt in the race as he pressures Mrs. Clinton to adopt more progressive positions.
''Bernie Sanders's campaign is having an effect on Hillary Clinton's policies,'' said Steve McMahon, a Democratic political consultant from Purple Strategies. ''From a progressive point of view, that's exactly what was hoped for and that is exactly what is happening.''
The idea of allowing people to buy in to Medicare has been discussed in policy circles and in Congress for decades. Mrs. Clinton's husband, former President Bill Clinton, floated a similar proposal in 1998, including it in his State of the Union address that year. The strategy has been embraced by many advocates of single-payer health care as a way to move more Americans into the existing government system. An incremental expansion of Medicare was the hoped-for strategy of Medicare's original authors.
But it is a new idea in Mrs. Clinton's presidential campaign. She has called for a range of health policy overhauls to preserve and expand the Affordable Care Act. She has proposed expanding financial protections for people with high health care costs and expanding subsidies to help middle-income people buy their own insurance. She also has proposed a package of policies to lower the price of prescription drugs.
But more recently, she has moved further. In February, she began discussing the possibility of a ''public option,'' a government-run insurance plan available to people shopping on the existing marketplaces. That idea was considered when the Affordable Care Act was being debated in Congress, but it was ultimately removed from the law.
Mrs. Clinton's latest suggestion regarding Medicare, first reported by Bloomberg News, takes another step by proposing that Americans still in their prime working years be given the opportunity to obtain the same government insurance that is provided on a universal basis to their older peers.
''The politics in the short term are good,'' said Jonathan Oberlander, a professor of health policy at the University of North Carolina at Chapel Hill. ''Medicare is a popular program -- people don't know too much about health reform, but people know about Medicare.''
Before the Affordable Care Act, people older than 55 tended to have difficulty buying their own insurance, because insurance companies saw them as bigger risks. Since the health law passed, insurance plans have been banned from discriminating against people based on health history, but they can charge premiums that are three times as much as younger adults are charged.
Moving more older adults into the Medicare program could have the effect of lowering insurance costs for younger people, as Mrs. Clinton suggested. But the exact dynamics would depend on how the program was structured.
Mrs. Clinton did not say, for example, whether lower-income Americans choosing Medicare would receive help paying their premiums, as they do when they buy private plans on the new marketplaces in the Affordable Care Act. Without such subsidies, Medicare might be an affordable option only for wealthy or very sick customers. In 2008, the Congressional Budget Office estimated that a Medicare buy-in program for 62- to 64-year-olds would cost about $7,600 a person.
Medicare tends to cover a wider range of doctors and services than commercial plans, but it also has more holes -- it has no limit on how much patients can be asked to spend out of their own pockets, for example. That means conventional Medicare would have different benefits and financial protections than private plans that are available to the 50-to-65 population.
''It's not a bad concept to be playing with and thinking about,'' said Linda J. Blumberg, a senior fellow at the Urban Institute, a left-leaning policy research group. ''But there are some complexities that need to be ironed out.''
Taking a more progressive stance on health care could serve Mrs. Clinton in a general election matchup against Donald J. Trump, the presumptive Republican nominee. He has offered a range of views on the subject. While he says that he wants to repeal the Affordable Care Act, he also has called for a system that would ensure that all Americans have health coverage.
Mr. Sanders is pressing on in his campaign and hopes to influence the party's platform at the July convention even if, as expected, he does not become the nominee. He has already pulled Mrs. Clinton to take more progressive stances on several issues, including supporting a higher minimum wage and opposing the Trans-Pacific Partnership trade deal and the Keystone XL pipeline.
Although Mr. Sanders viewed Mrs. Clinton's latest health care proposal as progress, he said on Tuesday that it was not sufficient.
''Secretary Clinton's proposal to let the American people buy into Medicare is a step in the right direction, but just like her support for a $12 minimum wage, it is not good enough,'' Mr. Sanders said in a statement that described her idea as ''Medicare for some.''
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
URL: http://www.nytimes.com/2016/05/11/us/politics/hillary-clinton-health-care-public-option.html
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GRAPHIC: PHOTOS: Hillary Clinton says she now favors the ''public option.'' (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES) (A1)
Hillary Clinton spoke on Tuesday with young parents at the Family Care Center in Lexington, Ky. (PHOTOGRAPH BY PATRICK SEMANSKY/ASSOCIATED PRESS) (A16)
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July 4, 2015 Saturday
Late Edition - Final
Insurers Seek Steep Increases in Plans' Rates
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1508 words
WASHINGTON -- Health insurance companies around the country are seeking rate increases of 20 percent to 40 percent or more, saying their new customers under the Affordable Care Act turned out to be sicker than expected. Federal officials say they are determined to see that the requests are scaled back.
Blue Cross and Blue Shield plans -- market leaders in many states -- are seeking rate increases that average 23 percent in Illinois, 25 percent in North Carolina, 31 percent in Oklahoma, 36 percent in Tennessee and 54 percent in Minnesota, according to documents posted online by the federal government and state insurance commissioners and interviews with insurance executives.
The Oregon insurance commissioner, Laura N. Cali, has just approved 2016 rate increases for companies that cover more than 220,000 people. Moda Health Plan, which has the largest enrollment in the state, received a 25 percent increase, and the second-largest plan, LifeWise, received a 33 percent increase.
Jesse Ellis O'Brien, a health advocate at the Oregon State Public Interest Research Group, said: ''Rate increases will be bigger in 2016 than they have been for years and years and will have a profound effect on consumers here. Some may start wondering if insurance is affordable or if it's worth the money.''
President Obama, on a trip to Tennessee this week, said that consumers should put pressure on state insurance regulators to scrutinize the proposed rate increases. If commissioners do their job and actively review rates, he said, ''my expectation is that they'll come in significantly lower than what's being requested.''
The rate requests, from some of the more popular health plans, suggest that insurance markets are still adjusting to shock waves set off by the Affordable Care Act.
It is far from certain how many of the rate increases will hold up on review, or how much they might change. But already the proposals, buttressed with reams of actuarial data, are fueling fierce debate about the effectiveness of the health law.
A study of 11 cities in different states by the Kaiser Family Foundation found that consumers would see relatively modest increases in premiums if they were willing to switch plans. But if they switch plans, consumers would have no guarantee that they can keep their doctors. And to get low premiums, they sometimes need to accept a more limited choice of doctors and hospitals.
Some say the marketplaces have not attracted enough healthy young people. ''As a result, millions of people will face Obamacare sticker shock,'' said Senator John Barrasso, Republican of Wyoming.
By contrast, Marinan R. Williams, chief executive of the Scott & White Health Plan in Texas, which is seeking a 32 percent rate increase, said the requests showed that ''there was a real need for the Affordable Care Act.''
''People are getting services they needed for a very long time,'' Ms. Williams said. ''There was a pent-up demand. Over the next three years, I hope, rates will start to stabilize.''
Sylvia Mathews Burwell, the secretary of health and human services, said that federal subsidies would soften the impact of any rate increases. Of the 10.2 million people who obtained coverage through federal and state marketplaces this year, 85 percent receive subsidies in the form of tax credits to help pay premiums.
In an interview, Ms. Burwell said consumers could also try to find less expensive plans in the open enrollment period that begins in November. ''You have a marketplace where there is competition,'' she said, ''and people can shop for the plan that best meets their needs in terms of quality and price.''
Blue Cross and Blue Shield of New Mexico has requested rate increases averaging 51 percent for its 33,000 members. The proposal elicited tart online comments from consumers.
''This rate increase is ridiculous,'' one subscriber wrote on the website of the New Mexico insurance superintendent.
In their submissions to federal and state regulators, insurers cite several reasons for big rate increases. These include the needs of consumers, some of whom were previously uninsured; the high cost of specialty drugs; and a policy adopted by the Obama administration in late 2013 that allowed some people to keep insurance that did not meet new federal standards.
''Healthier people chose to keep their plans,'' said Amy L. Bowen, a spokeswoman for the Geisinger Health Plan in Pennsylvania, and people buying insurance on the exchange were therefore sicker than expected. Geisinger, often praised as a national model of coordinated care, has requested an increase of 40 percent in rates for its health maintenance organization.
Insurers with decades of experience and brand-new plans underestimated claims costs.
''Our enrollees generated 24 percent more claims than we thought they would when we set our 2014 rates,'' said Nathan T. Johns, the chief financial officer of Arches Health Plan, which covers about one-fourth of the people who bought insurance through the federal exchange in Utah. As a result, the company said, it collected premiums of $39.7 million and had claims of $56.3 million in 2014. It has requested rate increases averaging 45 percent for 2016.
The rate requests are the first to reflect a full year of experience with the new insurance exchanges and federal standards that require insurers to accept all applicants, without charging higher prices because of a person's illness or disability. The 2010 health law established the rate review process, requiring insurance companies to disclose and justify large proposed increases. Under federal rules, increases of 10 percent or more are subject to review.
Federal officials have often highlighted a provision of the Affordable Care Act that caps insurers' profits and requires them to spend at least 80 percent of premiums on medical care and related activities. ''Because of the Affordable Care Act,'' Mr. Obama told supporters in 2013, ''insurance companies have to spend at least 80 percent of every dollar that you pay in premiums on your health care -- not on overhead, not on profits, but on you.''
In financial statements filed with the government in the last two months, some insurers said that their claims payments totaled not just 80 percent, but more than 100 percent of premiums. And that, they said, is unsustainable.
At Blue Cross and Blue Shield of Minnesota, for example, the ratio of claims paid to premium revenues was more than 115 percent, and the company said it lost more than $135 million on its individual insurance business in 2014. ''Based on first-quarter results,'' it said, ''the year-end deficit for 2015 individual business is expected to be significantly higher.''
BlueCross BlueShield of Tennessee, the largest insurer in the state's individual market, said its proposed increase of 36 percent could affect more than 209,000 consumers.
''There's not a lot of mystery to it,'' said Roy Vaughn, a vice president of the Tennessee Blue Cross plan. ''We lost a significant amount of money in the marketplace, $141 million, because we were not very accurate in predicting the utilization of health care.''
Julie Mix McPeak, the Tennessee insurance commissioner, said she would ask ''hard questions of the companies we regulate, to protect consumers.''
After public hearings and a rigorous review, Ms. Cali, the Oregon insurance commissioner, found that the cost of providing coverage to individuals and families in 2014 was $830 million, while premiums were only $703 million. She directed some carriers to raise rates in 2016 even more than they had proposed.
Health Net, for example, requested rate increases averaging 9 percent in Oregon. The state approved increases averaging 34.8 percent. Oregon's Health Co-op requested a 5.3 percent increase. The state called for a 19.9 percent increase.
''We share the concerns expressed through public comment about the affordability of health insurance in Oregon,'' said Ms. Cali, an actuary. But, she added, ''inadequate rates could result in companies going out of business in the middle of the plan year, or being unable to pay claims.''
Coventry Health Care, now owned by Aetna, is seeking rate increases that average 22 percent for 70,000 consumers in Missouri. ''The claims experience for these plans has been worse than anticipated,'' Coventry reported.
In its proposal to increase rates by an average of 25 percent for more than 397,000 consumers, Blue Cross and Blue Shield of North Carolina cited ''inpatient costs, particularly in treatment of cancer and heart conditions, emergency room utilization, and cost for specialty drug medications'' to treat hepatitis C, breast cancer and cystic fibrosis.
Blue Cross and Blue Shield of Kansas sought increases averaging 37 percent for 2016 and said the increase could affect 28,600 consumers.
''Kansans who purchased these individual plans since 2014 were older, in general, than expected and required more medical services than anticipated,'' the company told federal health officials.
URL: http://www.nytimes.com/2015/07/04/us/health-insurance-companies-seek-big-rate-increases-for-2016.html
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September 30, 2013 Monday
Obama Scolds House Republicans Over Possible Shutdown
BYLINE: Michael D. Shear
SECTION: US
LENGTH: 439 words
HIGHLIGHT: President Obama castigated House Republicans for failing to perform one of their most basic functions by not providing money for the government. He said a shutdown would harm the economic recovery.
President Obama castigated House Republicans for failing to perform a basic function by not providing money for the government. He said a shutdown would harm the economic recovery.
"The idea of putting the American people's hard-earned progress at risk is the height of irresponsibility and doesn't have to happen," he said. "Let me repeat that: It does not have to happen. All of this is entirely preventable."
Mr. Obama urged Republican lawmakers not to make "extraneous and controversial" ideological demands in exchange for keeping the federal government open, and said the impact of a shutdown on Tuesday would be harmful to millions of Americans.
"One faction of one party in one house of Congress in one branch of government doesn't get to shut down the entire government," Mr. Obama told reporters at the White House on Monday afternoon. "You don't get to extract a ransom for doing your job."
The president scolded opponents of the Affordable Care Act for insisting that the law be delayed or rolled back. He said that it will eventually provide affordable insurance to millions of people who have lived in fear of huge medical bills.
He said that the insurance marketplaces where people can shop for new coverage will open for business on Tuesday regardless of what Congress does. And he bluntly told critics of the law that they will not win in their crusade to undo his signature achievement.
"An important part of the Affordable Care Act takes effect tomorrow," Mr. Obama said. "That funding is already in place. You can't shut it down."
In remarks that took about ten minutes, Mr. Obama sought to describe the painful impact of a government shutdown, not only on federal employees but also on people who depend on services that the government would stop providing.
He said that Social Security recipients will continue to receive their checks and that Medicare patients will still be able to be seen by their doctors. Mail delivery will continue and essential personnel in the military, air traffic control booths, prisons and border patrols will stay on the job.
But he said that NASA will shut down "almost entirely" except for mission control operations dedicated to the astronauts on the International Space Station. He said federal office buildings will close, parks and monuments will be shut down, and veterans will find their support services unstaffed.
"Hundreds of thousand of these dedicated public servants who stay on the job will do so without pay," Mr. Obama said. "These Americans are our neighbors. Their kids go to our schools. They are the customers of every business in this country. They would be hurt greatly."
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November 18, 2011 Friday
Supreme Court Names Two Lawyers to Argue Points in Health Care Law
BYLINE: ADAM LIPTAK
SECTION: HEALTH
LENGTH: 374 words
HIGHLIGHT: The justices added lawyers to address the issues of whether the individual mandate can be severed from the rest of the law, and whether the appeals under way are premature.
WASHINGTON -- The Supreme Court on Friday made two prominent Washington lawyers very happy and very busy,appointing themto argue on behalf of positions that neither side in the challenges to the 2010 health care law has chosen to embrace.
The lawyers will submit briefs as friends of the court, and they will participate in the marathon arguments likely to take place in March.
The court invited H. Bartow Farr III to make the argument that the individual mandate -- the provision of the Patient Protection and Affordable Care Act that requires almost everyone to buy insurance or face a penalty -- "is severable from the entirety of the remainder of the act." That is what the United States Court of Appeals for the 11th Circuit held when it struck down the provision, sometimes called the minimum coverage provision.
But lawyers for the Obama administration have said the provision is intertwined with two other important parts of the law -- one forbidding insurers to turn away applicants, and the other barring them from taking account of pre-existing conditions. If the mandate falls, the administration argued, those provisions must fall with it.
The justices appointed a second lawyer, Robert A. Long, to argue that a federal law called the Anti-Injunction Act makes challenges to the mandate premature until 2015. The United States Court of Appeals for the Fourth Circuit, in Richmond, Va., accepted that argumentin September, and a dissenting judge on the United States Court of Appeals for the District of Columbia Circuit recently agreed.
The administration initially pressed this argument but later abandoned it.
The court has scheduled five and a half hours of arguments in the case. Ninety of those minutes will be devoted to severability, and an hour to the Anti-Injunction Act.
The court appoints outside lawyers to make orphaned arguments about once a term, though typically in minor cases. The practice has been the subject of some academic criticism, on the ground that it can amount to "judicial agenda-setting."
Insurers Weigh In on Health Care Law
Doctor Groups Seem Less Wary of Medicare Changes
Obama Pushes More Competition on Biologic Drugs
Study Finds Medicare Drug Plan Reduces Health Spending
This Week's Health Industry News
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January 4, 2016 Monday
Hillary Clinton Tells Democrats in Iowa: 'I Need You'
BYLINE: AMY CHOZICK
SECTION: US; politics
LENGTH: 378 words
HIGHLIGHT: At the start of a two-day tour of the state, Hillary Clinton said she would seek to improve the Affordable Care Act and backed the president’s proposed executive action on gun control.
As her husband tried to stay on message in New Hampshire, Hillary Clinton embarked on a "River to River" tour of Iowa on Monday, with six events across the state over two days.
With a new Republican-led effort to repeal the Affordable Care Act potentially up for a vote this week in Congress, Mrs. Clinton focused her remarks on her plans to preserve, but improve on, President Obama's sweeping health care plan.
"I want to bring costs down and make improvements to it," Mrs. Clinton told a crowd in Davenport, Iowa.
She also reiterated her support for Mr. Obama's proposed executive action on gun control and reminded the audience that a Republican president could easily undo the moves Mr. Obama is proposing. "They can be undone the first day," she said.
Mrs. Clinton did not specifically respond to attacks by Donald J. Trump, but instead tried to portray the entire Republican field as offering divisive language instead of solutions. "I am disturbed by the rhetoric I hear coming from the other side," Mrs. Clinton said.
"It's easy to tear down, it's hard to build up. It's easy to insult, it's easy to criticize," she continued. "But I don't think you get much done if that's the kind of rhetoric you use."
With the Iowa caucus approaching, Mrs. Clinton, who also held an organizing event in Cedar Rapids and planned a "Get Out the Caucus" event in Des Moines on Monday evening, has shifted from generically extolling the virtues of the caucus system to delivering with each selfie she snaps an impassioned plea for her supporters to show up on Feb. 1.
"I need you," she said over and over on the rope line in Davenport.
On Tuesday, Mrs. Clinton has stops scheduled in Osage, Sioux City and Council Bluffs. The campaign has dispatched surrogates including the actors Lena Dunham, Jamie Lee Curtis and Tony Goldwyn (star of ABC's "Scandal") and Gov. Terry McAuliffe of Virginia, a long-time friend of Mr. Clinton's, to campaign for Mrs. Clinton in Iowa in the coming weeks.
At one point, a voter asked Mrs. Clinton when Mr. Clinton would be campaigning in Iowa.
"He'll be here," she said. "He's in New Hampshire today."
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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November 16, 2012 Friday
Another G.O.P. Pyrrhic Victory
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 400 words
HIGHLIGHT: Several Republican governors have refused to set up insurance exchanges in their states, meaning the federal government will assume responsibility instead.
John Kasich of Ohio, Scott Walker of Wisconsin and Paul LePage of Maine are the latest Republican governors to announce a Pyrrhic victory for their party in the continuing fight over health care reform: They won't set up insurance exchanges, meaning the federal government will assume responsibility instead.
"Ohio will not let the federal government take over any regulatory control of its insurance industry," Mr. Kasich said in a statement, even though, as The Hill points out, "that's exactly what Kasich's decision does."
Likewise, John Boehner praised Mr. Kasich "for taking a stand and resisting the federal takeover of healthcare in Ohio"-neglecting to mention that the governor's move actually guarantees a federal takeover.
Other governors who've pledged to stick it to the feds by giving them direct power over state-based marketplaces include: Rick Scott, Bobby Jindal, Sam Brownback, Rick Perry, Nikki Haley, Nathan Deal, Robert McDonnell, Robert Bentley, Dave Heineman, and Sean Parnell. Needless to say they're all Republicans.
So many clichés of the cut-off-nose-to-spite-face variety come to mind. In Maine, according to The Portland Press Herald, "legislators from both parties" recognize that the governor's recalcitrance has put the state in a less-than-optimal situation. "Concerns about a federally-established exchange center on a lack of local control and a one-size-fits-all Web marketplace that may not work effectively, particularly in rural Maine where high-speed Internet access is limited. Some also worry that a federally-established exchange would include insurance plans that don't fit the coverage needs of Maine's population."
Rep. Sharon Treat, the ranking Democrat on the Maine Legislature's Insurance and Finance Committee, said: "We had plenty of chances to create our own exchange and manage it, but we wasted two years doing nothing. Now it's too late."
In a letter to Health and Human Services, Mr. LePage called the Affordable Care Act "a stepping stone to a single-payer system" and insisted that "Maine will not be complicit in the degradation of our nation's premier health care system." Two points: 1) Few Americans would call our old system "premier;" 2) Maine is now actively trying to damage our new system.
Health Care Under Romney: The Status Quo Ante
If It Works in Israel...
Roberts Hits the Reset Button
Health Care Confusion
Healthcare: What Might Have Been
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October 11, 2012 Thursday
Health Care Under Romney: The Status Quo Ante
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 498 words
HIGHLIGHT: In Ohio, the candidate suggested that the pre-reform health care system was good enough.
Mitt Romney, who has promised to "repeal and replace" the Affordable Care Act, but has never explained what the replacement will look like, hinted on Wednesday that his secret plan is to bring back the status quo ante.
At a rally in Mt. Vernon, Ohio, he said the A.C.A. was unnecessary for people with chronic conditions: "Actually, we had health care in America before Obamacare came along. And we still have health care in America." He added, "People who are poor are able to get Medicaid, which is a government support effort for those who can't afford to have insurance. And these things aren't going to disappear without Obamacare."
Yes, "we" had health care in America before the A.C.A. - in a manner of speaking. Some Americans had health care; others did not.
Mr. Romney seems to have conveniently forgotten that millions of people who are not poor enough for Medicaid do not have private insurance. According to the U.S. Census Bureau, roughly 4 in 25 Americans, or nearly 49 million Americans, had no health insurance last year. Moreover, the Congressional Budget Office estimates that repealing the A.C.A. would deny access to insurance to about 30 million Americans who would receive coverage if the president's reforms were to stay in place.
Mr. Romney also failed to mention that his budget proposal to cap federal spending at 20 percent of G.D.P. and boost defense spending to 4 percent of G.D.P. would result in massive cuts to Medicaid. The Center for Budget and Policy Priorities estimates that Medicaid and the Children's Health Insurance Program "would face cumulative cuts of $1.5 trillion through 2022 if Medicare is subject to cuts and $1.9 trillion if Medicare is exempt." As a result "14 to 19 million more people" would join "the ranks of the uninsured."
In a Wednesday meeting with the editorial board of an Ohio newspaper, The Dispatch, Mr. Romney again suggested that the pre-reform health care system was good enough, and also minimized the gravity of forgoing insurance.
"We don't have a setting across this country where if you don't have insurance, we just say to you, 'Tough luck, you're going to die when you have your heart attack.'" Instead "you go to the hospital, you get treated, you get care, and it's paid for, either by charity, the government or by the hospital. We don't have people that become ill, who die in their apartment because they don't have insurance."
So there you have it. The Romney plan: Let them have emergency care. Setting aside the fact that personal-responsibility types should feel appalled - Mr. Romney's endorsing cost-shifting from the patient to the general health-care market - it's not true that no one dies because they don't have insurance. Families USA, a health care advocacy group, issued a report in June indicating that 26,100 people between the ages of 25 and 64 died prematurely due to lack of health coverage in 2010.
Medicare Confusion
Forcing Flip-Flops
If It Works in Israel...
Flip Flopping Away
Romney's Call to Arms
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March 18, 2014 Tuesday
Late Edition - Final
New Health Law Is Sending Many Back to School
BYLINE: By PHYLLIS KORKKI
SECTION: Section F; Column 0; Continuing Education; CONTINUING EDUCATION SPECIAL SECTION; Pg. 9
LENGTH: 1101 words
PROFESSIONAL development classes constantly need to adapt to new realities, and that is especially true now in health care management, with the Affordable Care Act changing the rules for patients, managers, doctors and other health workers.
Key provisions of the law, including the requirement that most people obtain health insurance and the creation of online insurance marketplaces where individuals can buy insurance, are leading to new policies and practices down the line. Confusion has inevitably ensued. But that could mean career opportunities for professionals with the best and most current understanding of the law and the way it is being put into practice.
The University of California, Los Angeles modified its certificate program in health care management, begun in 2005, in part to address the Affordable Care Act passed four years ago. That law has moved forward despite website problems, delays of various provisions, administrative exemptions and legal and congressional challenges.
The certificate program, part of U.C.L.A. Extension, includes topics like financial management, leadership, health law and compliance, marketing and technology. The class of 2012 had 235 students, according to the university. The eight-course program, which costs students about $7,200, is aimed at professionals and aspiring professionals in health care, insurance, government and the nonprofit sector.
The key elements in a course about health insurance coverage and payments are different now from what they were even several years ago, said Dylan Roby, an assistant professor of health policy and management in the university's School of Public Health. Now, for example, insurance companies cannot price people out of the market because of pre-existing conditions, he said. In classes, ''You have to explain what happened and what's changed,'' he said.
Professor Roby created the introductory course in a new online-only certificate program for medical professionals -- including doctors, nurses, managers and administrators -- called Transformational Leadership in Health Care, which considers various facets of the new health law. That program, which began a year ago, costs around $7,000.
Two years ago, U.C.L.A. Extension also started a certificate program in patient advocacy -- on campus and online -- as more people take jobs helping patients and their families navigate a maze of treatment and billing issues. That certificate costs about $5,600.
Professor Roby said the U.C.L.A. programs were intended to be pragmatic. Although he says he personally thinks the Affordable Care Act ''is a step in the right direction and does make it much easier for people to obtain comprehensive insurance coverage,'' the coursework also looks at ''potential failures and what the A.C.A. does and does not do to solve them.''
''You're flying by the seat of your pants with the A.C.A.,'' said Lisa Labellarte of Los Angeles, who finished the university's patient advocacy program last year. In 2012 she started a patient advocacy company called Sequoia Health Advocates in Los Angeles. Her son, now 13, was born with medical problems and her sister developed breast cancer. Ms. Labellarte became an advocate for them, which evolved into wanting to go into business to do the same for others.
As an example, she said, she helped an American who lived outside the United States obtain insurance through the California marketplace so he could return to this country for medical treatment -- a process that proved to be difficult and required up-to-date knowledge of the law.
Ms. Labellarte has found that some of what she learned in the patient advocacy program, especially about insurance, is now outdated. For that reason, she and others have talked with administrators of the program about what to include in future classes as the new health law continues to play out.
She and others in health care sometimes face difficult ethical questions about treatment and coverage. The new law is affecting the very nature of the quandaries that arise, said Robert Klitzman, director of the masters of bioethics program at Columbia University, run through the School of Continuing Education. He has had to alter the program as a result.
Questions his program now addresses include: Does the government have the right to demand that people buy health insurance, and should they be penalized if they don't? What is a minimal level of care? How do you allocate scarce resources? How do you prevent cost overruns? Should the government provide infertility treatments under the new law, or should that be considered an elective service and, if so, for whom? How much should the government oversee drug companies? The list goes on.
Issues like these have become concrete in a way they never were before, said Professor Klitzman, a psychiatry professor at the Columbia College of Physicians and Surgeons and the Mailman School of Public Health.
The M.S. program costs around $60,000, with federal loans available. Students include working professionals who are in the health field or seeking to enter it, he said. Pre-med students sometimes do the coursework after graduating and before applying to medical school, he said.
He also set up online bioethics courses and a certificate program, which started a year ago. The certificate program costs about $20,000, but classes can also be taken individually and without credit for as little as around $1,650 each. Students can receive continuing medical education credit for the courses.
Professor Klitzman says he personally thinks that the Affordable Care Act has many positive aspects, particularly because it helps people who are uninsured and underinsured, but he does not see it as a solution to the nation's health care problems. The program itself looks at the law's pros and cons and brings in speakers on both sides of the issue, he said. Any policy that addresses a complex social problem will result in unintended consequences and trade-offs, he said, and health care workers need to be aware of them.
Katherine Zavin, a student in the bioethics program, took a class through Columbia Law School called Access to Health Care, which focused on the Affordable Care Act. ''The best part of the course was that since many aspects of the A.C.A. were going into effect while the course was going on, we talked about political reactions and possible legal reactions in current time,'' she said in an email.
''Bioethics gives you a structure to understand what's going on in the bigger picture,'' Professor Klitzman said. ''We need to equip our students to work in this rapidly evolving world.''
URL: http://www.nytimes.com/2014/03/18/education/new-health-law-is-sending-many-back-to-school.html
LOAD-DATE: March 20, 2014
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GRAPHIC: PHOTO: MAPPING THE MAZE: Lisa Labellarte, who is a patient advocate, says, ''You're flying by the seat of your pants with the A.C.A.'' (PHOTOGRAPH BY SANDY HUFFAKER FOR THE NEW YORK TIMES)
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December 5, 2016 Monday 00:00 EST
The Art of the Scam;
Op-Ed Columnist
BYLINE: PAUL KRUGMAN
SECTION: OPINION
LENGTH: 833 words
HIGHLIGHT: Prepare for government by bait and switch.
Remember Donald Trump's tax returns? It was unheard-of for a presidential candidate to refuse to release returns, since doing so strongly suggests that he has something to hide. And at first the Trump campaign offered excuses, claiming that the returns would eventually be made available once an I.R.S. audit was done, or something. But at this point it's apparent that Mr. Trump believed, correctly, that he could violate all the norms, stonewall on even the most basic disclosure, and pay no political price.
Indeed, it's clear that Hillary Clinton was in effect punished for her financial transparency, while Mr. Trump was rewarded for his practice of revealing nothing about how he makes money.
And as a result, we can expect radical lack of transparency to be standard operating procedure in the new administration. In fact, it has already started.
Take, for example, the budget process. Normally, an incoming administration issues a fiscal plan conveying its priorities soon after taking office. But as the budget expert Stan Collender notes, there are strong indications that the Trump administration will ignore this precedent (and, possibly, the law) and simply refuse to offer any explanation of how its proposals are supposed to add up. All we'll get, probably, are assurances that it's going to be great, believe me.
True, we don't yet know for sure that there will be no budget. But it's already clear that bait-and-switch - big but empty promises, completely lacking in detail - will be central to Republican strategy on one key issue: the future of health coverage for millions of Americans.
The background: Back in 2010 President Obama and the short-lived Democratic majority in Congress passed the Affordable Care Act with zero G.O.P. support. Ever since, Republicans have promised to repeal the law as soon as they had a chance, replacing it with something much better. Strange to say, however, they have never described what their replacement would look like.
And I don't mean that they haven't spelled out all the details. Almost seven years after Obamacare was enacted, Republicans haven't offered even the broad outline of a health reform plan. Why not?
Actually, there's no mystery here. While many Americans say they disapprove of Obamacare, large majorities approve of the things the Affordable Care Act does, notably ensuring that people with pre-existing medical conditions can still buy insurance. And there's no way to achieve these things without either a major expansion of government health programs - hardly a Republican priority - or something very much like the law Democrats passed.
Worse yet, from the Republican point of view, Obamacare has worked. It's not perfect, by a long shot, but the number of uninsured Americans has plummeted to its lowest level in history. And Americans newly insured thanks to Obamacare are highly satisfied with their coverage.
So what can the G.O.P. offer as an alternative? We know what Republicans want: a free-for-all in which insurance companies can discriminate as they like, with minimal regulation and drastic cuts in government aid. Going there would, however, cause millions of Americans - many of them people who voted for Trump, believing that their recent gains were safe - to lose coverage. The political blowback would be terrible.
Yet failing to repeal Obamacare would also bring heavy political costs. So the emerging Republican health care strategy, according to news reports, is "repeal and delay" - vote to kill Obamacare, but with the effective date pushed back until after the 2018 midterm elections. By then, G.O.P. leaders promise, they'll have come up with the replacement they haven't been able to devise over the past seven years.
There will, of course, be no replacement. And there's likely to be chaos in health care markets well before Obamacare's official expiration date, as insurance companies exit markets they know will soon collapse. But the political thinking seems to be that they can find a way to blame Democrats for the debacle.
It's all very Trumpian, if you think about it. An honest memoir of the president-elect's business career would be titled "The art of the scam." After all, his hallmark has been turning a profit on failed business projects, because he finds a way to leave other people holding the bag.
In this case, the effort to replace Obamacare will clearly fail miserably in terms of serving the American people, perhaps especially the white working-class voters who backed Mr. Trump. But it could nonetheless be a political success if the public can be convinced to blame the wrong people.
You might think that this would be impossible, given the obviousness of the ploy. But given what we've seen so far, you have to take seriously the possibility that they'll get away with it.
Read my blog, The Conscience of a Liberal, and follow me on Twitter, @PaulKrugman.
Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter.
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November 7, 2014 Friday
Supreme Court to Hear New Health Law Challenge
BYLINE: ADAM LIPTAK
SECTION: US; politics
LENGTH: 90 words
The Supreme Court on Friday agreed to hear a new challenge to the Affordable Care Act, imperiling President Obama's signature legislative achievement two years after it survived a separate Supreme Court challenge by a single vote.
Whoa. #Scotus agrees to hear new challenge to Affordable Care Act.
- Adam Liptak (@adamliptak)7 Nov 14
Take a look at our colleague Robert Pear's recent stories on the subject:
U.S. Cannot Subsidize Health Plans in States With No Marketplace, a Judge Rules
New Questions on Health Law as Rulings on Subsidies Differ
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(The Caucus)
February 26, 2014 Wednesday
Clinton Addresses a Key Constituency at the University of Miami
SECTION: US; politics
LENGTH: 476 words
HIGHLIGHT: Hillary Rodham Clinton talked about foreign policy, the Affordable Care Act and the importance of the Millennial Generation during a talk Wednesday night at the University of Miami.
Hillary Rodham Clinton fielded questions from college students in Miami on Wednesday evening, and in the process positioned herself as sympathetic to a younger generation's concerns about the country and its political leaders.
In a wide-ranging talk at the University of Miami, Mrs. Clinton talked about tolerance and inclusion. "I hope your generation will be a true participation generation," she said. "I hope you will find ways that the barriers that too often divide us are torn down once and for all."
She also weighed in on the legislation in Arizona that would have allowed businesses to deny service to gays and lesbians. "Thankfully, the governor of Arizona has vetoed the discriminatory piece of legislation that had passed," Mrs. Clinton said to applause.
Sounding at times as if she were still secretary of state, Mrs. Clinton discussed the crisis in Syria and called for the removal of the Assad regime's chemical weapons stockpiles. "This is an issue I've certainly spent a lot of time working on and worrying about both when I was in the government and in the time since," she said.
The students, many of them Latino, also questioned Mrs. Clinton about the violence in Venezuela. "We tried to engage President Chávez," Mrs. Clinton said of former President Hugo Chávez and referring to her tenure at the State Department. But she said the United States had made no headway in its relationship with Venezuela, despite what she said were the Obama administration's best efforts with Mr. Chávez - who died a year ago - and his successor, President Nicolas Máduro.
On the domestic front, Mrs. Clinton defended the Affordable Care Act, warning that young people who think they are invincible need health insurance. If all Americans are covered, she added, insurance costs would come down.
Mrs. Clinton used the talk to praise the Millennial Generation - generally defined as those born from the early 1980s to the early 2000s. The voters of that generation would be crucial to Mrs. Clinton if she decides to run for president in 2016.
"If you look at what's happening in our country today, it's clear that the so-called Millennials are really representative of a generous and active generation," she said.
At the end of the event, the university's president, Donna Shalala, a longtime Clinton friend who was secretary of health and human services in the Clinton administration, coyly tried to discern Mrs. Clinton's 2016 plans. She asked if the former first lady would reveal the meaning of "TBD" in her personal Twitter description. Mrs. Clinton replied: "I'd really like to, but I have no characters left."
Pro-Clinton 'Super PAC' Sets Event for Donors
Lawmakers Go on the Record for Clinton
Clinton Defender Takes On Fox News Over Benghazi Attack
Hillary Clinton, Waxing Nostalgic, Accepts Award at Yale
Bill Clinton to Raise Cash for Democratic Governors
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September 19, 2013 Thursday
'Creepy Uncle Sam' Is Anti-Health Care Law Mascot
BYLINE: ABBY GOODNOUGH
SECTION: US; politics
LENGTH: 581 words
HIGHLIGHT: The group Generation Opportunity released a series of advertisements as part of a six-figure campaign to discourage people aged 18 to 29 from enrolling in insurance exchanges under the Affordable Care Act.
A group seeking to persuade young people to "opt out" of President Obama's health care law posted videos on YouTube Thursday that show young patients on exam tables recoiling in fear as a character the group is calling "Creepy Uncle Sam" appears out of nowhere and looms over them.
The group, Generation Opportunity, said in a news release that the videos were part of a new, six-figure campaign to educate people between the ages of 18 and 29 about "alternatives to expensive and creepy Obamacare exchanges."
Starting Oct. 1, uninsured Americans will be able to shop for health insurance through new online markets, or exchanges, in every state. Many low- and middle-income people will qualify for federal subsidies to help cover the cost. The Obama administration is eager for healthy young people to enroll in the exchanges, to help offset the cost of insuring older and sicker people.
Evan Feinberg, the president of Generation Opportunity, said in an interview that the group would spend "close to three-quarters of a million dollars" on the campaign, which will include not just online videos but also events at college football games, music festivals and other gatherings that tend to draw young adults. The group will ask young people to pledge not to sign up for insurance through the exchanges, Mr. Feinberg said.
"We talk to folks on a daily basis about what their options are - that they have ability to pay the penalty and buy health coverage that better meets their needs and their budget," he said.
Under the Affordable Care Act, starting in January, most Americans who do not have health insurance will have to pay a tax penalty. In the first year, it will be $95, or 1 percent of family income, whichever is higher.
Generation Opportunity is based in Virginia, but Mr. Feinberg said the campaign would be national. The group received $5 million last year from Freedom Partners, a nonprofit with ties to Charles G. and David H. Koch, according to tax filings. Mr. Feinberg said he worked at the Charles Koch Institute before joining Generation Opportunity earlier this year.
One of the videos shows a nurse escorting a young woman into an exam room, saying, "I see you chose to sign up for Obamacare." It then shows the young woman in a hospital gown, putting her feet in stirrups for a gynecological exam. Then the Uncle Sam character pops up at the end of the exam table, the young woman screams, and the words, "Don't let government play doctor" and "Opt out of Obamacare" flash on the screen.
The videos quickly drew criticism from supporters of the health care law. Brad Woodhouse, president of Americans United for Change, a left-leaning advocacy group, called them "sick, dishonest, vile and dangerous ads to scare young people into going without health insurance."
Ilyse Hogue, president of Naral Pro-Choice America, said in a statement that the video featuring the young woman "not only defiles our American mascot but disturbingly compared the A.C.A. to sexual assault."
Mr. Feinberg dismissed such criticism, saying, "All the ad suggests is that Uncle Sam will play doctor."
He added: "I'll tell you this, we got some early feedback from folks on college campuses. A lot of people are planning on dressing as Creepy Uncle Sam for Halloween."
Father and Son Declare a Political Truce, for 60 Seconds
House G.O.P. Delays Vote on Stopgap Budget Measure
Immigration Campaign to Target 11 House Republicans
The Early Word: Escalating
Manchin Has Retort for N.R.A. in New Ad
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November 13, 2013 Wednesday
Late Edition - Final
Obama in Bind Trying to Keep Health Law Vow
BYLINE: By MICHAEL D. SHEAR and ROBERT PEAR; Sharon LaFraniere contributed reporting from New York.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1148 words
WASHINGTON -- Under intense bipartisan pressure to answer mounting consumer complaints about the botched health care rollout, White House officials are struggling to make good on President Obama's promise that Americans can keep their insurance coverage without undermining the new health law or adding unaffordable costs.
After the president's apology last week for wrongly assuring Americans that they could retain their health plans if they wanted, senior White House aides said the president wanted to ensure that people who were forced off older policies with less comprehensive coverage were not stuck with higher monthly premiums to replace their insurance. But administration officials declined to say how they might achieve that goal, how much it would cost or whether it would require congressional approval.
At the same time, officials signaled the president's strong opposition to calls from across the political spectrum -- including one Tuesday from a key ally, former President Bill Clinton -- to support bipartisan legislation that would allow people to keep their current insurance plans even after provisions of the Affordable Care Act go into effect next year.
White House officials refused to discuss in detail what options Mr. Obama was considering. But they made clear that the president was skeptical of any solution that would allow insurance companies to continue selling what officials consider to be cheap and substandard policies.
''Broadly speaking, we do not see that as fixing the problem,'' Jay Carney, the White House press secretary, said Tuesday.
The split between lawmakers and the White House reflects the dilemma the president finds himself in as he seeks to follow through on last week's acknowledgment about his incorrect promise on health care coverage. Hundreds of thousands of people have received cancellation notices from health insurance companies because their plans do not conform with minimum standards set by the new law.
With lawmakers promoting their simple-sounding solution, the challenge for Mr. Obama is to find a workable and politically practical way to address the issue to the satisfaction of those who have lost policies.
''Any fix that would essentially open up for insurers to sell new plans that did not meet the standards would create more problems than it would fix,'' Mr. Carney told reporters. It was unclear how the administration could make new plans more affordable, or whether that solution would be interpreted by Americans as keeping the promise that the president made in selling the health care law. Republicans in Congress would be certain to oppose efforts by the White House to expand subsidies.
The idea of passing legislation to allow all Americans to keep their coverage got a fresh boost on Tuesday when Mr. Clinton added his voice to the debate. In an interview, Mr. Clinton joined the intensifying criticism of the health care rollout and called on Mr. Obama to accept a change in the health care law that would allow insurance companies to keep selling policies that do not meet the new standards.
''I personally believe even if it takes a change in the law, the president should honor the commitment the federal government made to those people and let them keep what they got,'' Mr. Clinton said in the interview, published by Ozy, a web magazine.
Mr. Clinton, who tried to pass a health care overhaul during his presidency, has been a powerful advocate for the Affordable Care Act, especially among the president's key Democratic constituencies. And Mr. Clinton's wife, Hillary Rodham Clinton, is weighing a White House bid in 2016 that could be affected by the fortunes of the health care law.
Mr. Clinton followed a steady stream of Democrats who have announced their support for legislation to let people keep their coverage. Senator Dianne Feinstein, Democrat of California, endorsed one such effort by Senators Mary L. Landrieu of Louisiana and Joe Manchin III of West Virginia, both Democrats.
''Since the beginning of September, I have received 30,842 calls, emails and letters from Californians, many of whom are very distressed by cancellations of their insurance policies and who are facing increased out-of-pocket costs,'' Ms. Feinstein said. ''The Landrieu bill is a common-sense fix that will protect individuals in the private insurance market from being forced to change their insurance plans.''
Ms. Landrieu, who faces a difficult election fight next year, said the cancellation notices ''should have never gone out.''
''We said, and the president said over and over, that if people have insurance and they like the insurance they have, they can keep it,'' Ms. Landrieu said. ''That is my bill. That is the single focus of my bill. It is not to undermine the Affordable Care Act. It is to strengthen it and to keep our promise to millions of Americans.''
The White House declined to comment specifically on Ms. Landrieu's bill, but said that another effort by Representative Fred Upton, Republican of Michigan,and the chairman of the House Energy and Commerce Committee, was especially problematic. Under Mr. Upton's bill, an insurer that had individual policies in effect on Jan. 1 of this year could continue to ''offer such coverage for sale during 2014'' in the market outside an exchange.
Representative Henry A. Waxman of California, the senior Democrat on the Energy and Commerce Committee, denounced the bill as an effort to undermine the health care law.
''The bill would continue to allow insurers to exclude people from coverage based on pre-existing conditions,'' Mr. Waxman said. ''It would allow insurers to charge women twice as much as men for the same coverage.''
The concerns from Mr. Waxman and the White House echo those of insurance company executives themselves, who say the legislation under consideration would create huge operational challenges. Insurance is generally regulated by the states, they say, and the old policies have not been approved for sale beyond next month.
With just over a month before the deadline for consumers to enroll for coverage that begins Jan. 1, it is still not clear how many people have managed to sign up for coverage. Projections based on a Nov. 3 report attributed to the Blue Cross and Blue Shield Association suggest that at most 40,000 people had enrolled for insurance through the online federal exchange by Nov. 3.
The association decided to stop issuing its weekly enrollment report after The Wall Street Journal published an article on the numbers, according to two people familiar with the decision. In a statement, Alissa Fox, a vice president at the association, said she had not seen the enrollment report and could not verify that it was authentic.
Insurers say that allowing people to keep their existing policies would upend the assumptions built into new policies and rates for next year and lead to higher premiums for consumers.
URL: http://www.nytimes.com/2013/11/13/us/bill-clinton-urges-obama-to-yield-on-health-law.html
LOAD-DATE: November 13, 2013
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GRAPHIC: PHOTO: President Obama and former President Bill Clinton in September. Mr. Clinton urged the president on Tuesday to change the health care law to let all Americans keep their current policies. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES) (A18)
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October 1, 2013 Tuesday
In Debut, Affordable Care Web Site Baffles Many Users
BYLINE: Nick Bilton
SECTION: US
LENGTH: 606 words
HIGHLIGHT: While glitches hampered access to the Heatlhcare.gov Web site in its first day of operation, many early users liked the look.
While the federal Affordable Care Act is intended to narrow the divide between those with health care and those without, in its first day of operation the Web site aimed at helping consumers sign up for health insurance - Healthcare.gov - might have driven a larger wedge between technologically adept Americans and those who have yet to fully embrace the social Web and mobile technology.
The site encouraged people to "connect" via Twitter, Facebook and YouTube. It also provided a phone number to call, but doing so resulted in a long wait for assistance.
While the site's search feature seemed very intuitive, often returning detailed results for queries, including "sign up for account" or "sign up for coverage," some questions returned a blank page that simply said "No Results." In a bit of unintentional irony, the page then asked if an answer was helpful.
Those who did make it onto the Web site seemed to appreciate the design and aesthetics. The site looks like one for a typical start-up, with clean typography and large identifiable buttons that provide direction. Unlike most government sites, Healthcare.gov feels like it was built for today's Web users, rather than something that still belongs in a 1990s-era Web browser.
Perhaps the best experience for exploring and signing up for the Web site is on a smartphone; the site looks beautiful and is simple to navigate on an Apple iPhone and devices using Google's Android operating system. People can even sign up for the service on the mobile Web site, not just browse FAQs as is the case on the mobile sites of most other government agencies.
But not everyone was happy with the look and feel of the overall experience. Some complained that the site was too busy and complex, and that navigation was baffling.
"The http://healthcare.gov site is kind of confusing," Gilly Wonka of Georgia wrote on Twitter. A friend instantly replied to Mr. Wonka, adding a single word: "Very!"
While the site took three years to build, it took only a few minutes for it to break when it went live at 8 a.m. E.D.T.
Some consumers said they were met with an error message in the early morning when trying to visit the Web site, which seemed to be overwhelmed with traffic and limited by apparent programming issues.
Many people took to Twitter and Facebook to note that the site was down.
"And http://healthcare.gov is already broken ..." Kelly Campbell, a software engineer for Philadelphia, wrote on Twitter. "Can't sign up for an account because all the security question options are blank."
Ms. Campbell was referring to a series of three security questions that were showing up blank for some people, a series of question marks and programming code to others or simply as error messages.
One of the site's error messages read: "We have a lot of visitors on our site right now and we're working to make your experience here better. Please wait here until we send you to the login page. Thank you for your patience!" Another declared: "The system is down at the moment. We're working to resolve the issue as soon as possible. Please try again later."
In a statement, Healthcare.gov officials said they were aware of the problems and working to fix them.
"Thanks for all your comments and updates as you enroll. We apologize that wait times on the site and hotline are longer than expected!" the agency said. "We're working to fix these issues as soon as possible. Thanks for your patience."
For Many, Personal Service Is More Helpful Than Web Site
Medical Device Industry Fears Law's Tax on Sales
Picking a Plan and a Cobra Choice
Polls in Overtime on Affordable Care Act
A Scramble as Day 1 Approaches
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March 4, 2015 Wednesday
Late Edition - Final
Obama's Plan: Signal to Justices They're Health Law's Only Hope
BYLINE: By MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1305 words
WASHINGTON -- As the Supreme Court prepares to hear arguments on Wednesday on whether to invalidate a crucial part of the president's health care law, Obama administration officials say they are doing nothing to prepare for what could be a catastrophic defeat.
Administration officials insist that any steps they could take to prepare for the potential crisis would be politically unworkable and ineffective, and that pursuing them would wrongly signal to the justices that reasonable solutions existed. The do-nothing strategy is meant to reinforce for the court what White House officials believe: that a loss in the health care case would be unavoidably disastrous for millions of people.
There are no contingency plans in place if the court invalidates the Affordable Care Act subsidies that 7.5 million people in 34 states are receiving, administration officials said. No one is strategizing with governors or insurance company executives or lawmakers. There is no public relations plan to reassure people who might suddenly have to pay more for insurance.
If the court rejects the subsidies -- a decision unlikely to arrive until the end of the session in late June or early July -- health experts said premiums could triple within weeks, causing millions of people to lose coverage. That could quickly lead to a collapse of the health insurance markets in two-thirds of the country.
''If they rule against us, we'll have to take a look at what our options are. But I'm not going to anticipate that,'' President Obama said Monday in an interview with Reuters. ''I'm not going to anticipate bad law.''
The strategy echoes the administration's refusal through most of 2012 to acknowledge any planning for the effect of across-the-board budget cuts known as sequestration, insisting that the draconian cuts would never come to pass. (They did.) Also in 2012, the White House and its allies said there were no plans for the Supreme Court ruling on a challenge to the health law's individual mandate. (The court upheld the mandate.)
In the current health care case, legal experts said the White House was savvy in making clear that the situation was dire. They said the justices regularly considered the broader effect of their decisions and often took into account how the executive branch or Congress might respond to a ruling.
Jeffrey L. Fisher, a law professor at Stanford University, said the justices are likely to talk about the administration's lack of contingency plans when they meet behind closed doors on Friday for their first conference after hearing arguments.
''They are going to think about whether they buy it, whether they think it's strategy,'' Mr. Fisher said. ''It's something that a court would traditionally at least put into the melting pot of consideration.''
The latest legal challenge to the Affordable Care Act was brought by opponents who say Congress authorized subsidies to be issued only to people who signed up for coverage in one of 17 state-run marketplaces, not those who enrolled through the federal HealthCare.gov website. Government lawyers say lawmakers intended the subsidies to be available everywhere.
Mr. Obama's advisers continue to say they are confident the law will survive the court challenge. But if it does not, within weeks of the ruling the government will have to stop sending tax credits to insurance companies on behalf of the millions who signed up through HealthCare.gov and were promised hefty subsidies to offset the cost of premiums.
Most of those people would no longer be required by the law's individual mandate to have insurance, because part of the law provides exemptions when affordable insurance is not available. As a result, all but the sickest would choose to cancel their insurance, experts predicted.
With healthy people no longer choosing to be covered, experts said, most insurance companies would pull out of the markets in those states rather than cover only the sickest -- and most expensive -- customers.
The result would be a ''death spiral,'' according to the Supreme Court brief filed by America's Health Insurance Plans, the nation's health insurance trade group. ''It would leave consumers in those states with a more unstable market and far higher costs,'' the group argued in the brief.
Soon after the ruling, health care experts said, the White House could work with lawmakers to pass new legislation clarifying that the subsidies should be available everywhere. But that would require the unlikely support of Republicans who have fiercely opposed the president's law and sought to repeal it.
''It would take a wrecking ball to a major part of the Affordable Care Act,'' Representative Chris Van Hollen, Democrat of Maryland, said of a loss in the court. ''It's hard to see how it would be fixed, absent legislation. And Republicans have made it clear they have no interest in fixing it.''
Experts said the administration could encourage more states to set up their own insurance marketplaces, which are permitted to provide subsidies. Health experts said the administration could also provide waivers, financial assistance or technical expertise to help the states, although the process could take years to complete. States with a Republican governor or legislature are likely to refuse.
The federal government could also approve the formation of regional insurance marketplaces, but political leaders in the states would have to agree to participate.
''There aren't any magic solutions here,'' said Timothy Stoltzfus Jost, a professor at the Washington and Lee University School of Law.
If the court throws out the subsidies, experts say, it is unclear whether Mr. Obama, the court or Republicans will be blamed for the confusion.
''A court decision would unleash a giant game of political chicken,'' said Larry Levitt, a senior vice president of the Kaiser Family Foundation, a nonprofit organization that does research on health care. ''How that ends up would depend a lot on who is getting the blame for the chaos that would ensue.''
The situation has already enraged the administration's Republican critics, who hope the court will do what they have been unable to accomplish in Congress: unravel the president's chief domestic accomplishment.
''By admitting they have no contingency plan to assist the millions that may lose subsidies, the administration confirms how the misguided law is unworkable for the American people,'' Senator Orrin G. Hatch, Republican of Utah, said last week.
Mr. Hatch is part of a Republican group that is working on proposals to help stabilize the insurance markets in the aftermath of a ruling against the government. He said the goal of the group's efforts was to eventually repeal and replace the president's health care law.
''We would provide financial assistance to help Americans keep the coverage they picked for a transitional period,'' Mr. Hatch and two other senators wrote in a letter in The Washington Post this week.
In the House, Representative Paul D. Ryan, Republican of Wisconsin and chairman of the Ways and Means Committee, and several other lawmakers are proposing legislation to allow states to opt out of the Affordable Care Act and to provide tax credits to buy health insurance that could help people who might lose their subsidies.
The Republican lawmakers have not offered details of their proposals, but Mr. Obama's allies said they expected the Republicans to do little to ease the crisis if people could no longer receive subsidies.
''They should not be under any illusions that you can easily pick up the pieces,'' Mr. Van Hollen said of the nine justices. He said the Supreme Court should keep that in mind as it heard the case.
''If they render a decision that blows a hole in the law,'' Mr. Van Hollen said, ''there is no tidy fix to this.''
URL: http://www.nytimes.com/2015/03/04/us/politics/obama-administration-says-it-has-no-plan-if-supreme-court-rules-against-health-law.html
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GRAPHIC: PHOTO: A woman choosing a health plan in Iowa, one of the states where subsidies could be eliminated by a Supreme Court ruling. (PHOTOGRAPH BY ANDREW DICKINSON FOR THE NEW YORK TIMES) (A16)
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May 1, 2014 Thursday
Late Edition - Final
Implications for Employers in New Health Care Law
BYLINE: By NEIL IRWIN
SECTION: Section A; Column 0; National Desk; THE UPSHOT; Pg. 3
LENGTH: 1066 words
The days of Americans getting health insurance through their employers may be numbered -- and the change could be just as profound as the shift of employers forcing employees to manage their own retirement savings.
As the Affordable Care Act goes from thousands of pages of legalese to actual, real-life public policy, the future of employer-provided health insurance is one of the most fascinating questions. Will employers call for -- and their workers accept -- the practice of buying health insurance through government exchanges? How much will companies save, and will they pass those savings onto employees? Will it make workers more mobile and ready to shift jobs, or will employer-paid health insurance become a sought-after perk?
The answers go to the heart of how things work in a sector that is one-eighth of the American economy. A new report gives some hints of how large the impact might be.
By 2020, about 90 percent of American workers who now receive health insurance through their employers will be shifted to government exchanges created by the health law, according to a projection by S&P Capital IQ, a research firm serving the financial industry.
It's not an outlandish notion. Ezekiel Emanuel, an architect of the Affordable Care Act, has long predicted a similar shift.
But the scope and speed of the shift is surprising. So is the amount of money that companies could save. The S&P researchers tried to estimate what it would save the biggest American companies. Their answer: $700 billion between 2016 and 2025, or about 4 percent of the total value of those companies. The total could reach $3.25 trillion for all companies with more than 50 employees.
They assume those savings will accrue to companies' bottom lines, though there are also compelling reasons to think that some of those savings would end up in the pockets of American workers in the form of higher wages or other benefits.
The idea is this: Now that federal and state exchanges exist where anyone, even those with pre-existing illnesses, can gain coverage, employers might decide to give their workers a stipend to pay for health insurance on the exchanges rather than sponsor a plan themselves.
In truth, the American system of health care -- in which most people get their private health insurance through their employer -- has always been rather odd. Why should quitting a job also mean you have to get a new health insurance plan? Why should your boss get to decide what options you have and negotiate the cost of them? Employers don't get to select our auto insurance or mortgage company, so why should health insurance be any different?
If there is uncertainty around how the employer-provided health insurance system will evolve, there is even more around who will ultimately pay the bill. It could be the federal government, via insurance subsidies, or individuals who must pay for more of their health care. In a perfect world, lower costs would come from a more efficient system that provides better care at lower costs. But no one knows what the actual system of, say, 2025 will look like, any more than people could have foreseen the decline of pensions when the 401(k) option was added to the tax code.
Michael G. Thompson, managing director at S&P Capital IQ, argues that the parallel with defined-benefit pension plans is an apt one. For decades, those plans were a major benefit offered by large employers. But as other options became available that allowed employers to more cheaply provide retirement benefits with fewer administrative headaches, which 401(k)s provided, employers shifted to 401(k)s en masse.
''We still expect some companies to hold on to their health care plans, just as some private companies still have pensions,'' Mr. Thompson said. ''But we think that the tax incentives for employer-driven insurance are not enough to offset the incentives for companies to transition people over to exchanges and have them be more autonomous around management of their own health care.''
The advantages are particularly clear for companies with lower-paid workers, who may be eligible for federal subsidies under the Affordable Care Act aimed at those employees making up to 400 percent of the poverty line.
Not everyone is so sure. Employers may not love the administrative challenges of administering a health plan, but they have been offering these plans voluntarily for decades, because employees value the perk. An employer who backs away from offering a health insurance plan directly, instead sending workers to the exchanges, may lose a competitive advantage in hiring. (Yet companies' experience with substituting 401(k)s for pensions may have taught them that employees had little choice in the transition, and just accepted it.)
There is another strong reason that employers might not rush for the exits. When an employer subsidizes a worker's health insurance plan directly, the subsidy is tax free to the employee. So the employer is effectively getting more bang for the buck in its total compensation. If an employer gives its workers extra pay to help them buy health insurance on an exchange, that money is taxable income.
Add to that a $2,000 per-worker annual penalty that the Affordable Care Act charges large employers that do not provide insurance, and the pathway toward employers dropping coverage may not be as short and direct as the S&P researchers suggest.
''For most firms, there isn't a net gain to dropping coverage for active workers,'' said David Cutler, a health economist at Harvard who advised the Obama administration in writing the law. ''The subsidies are more than offset by the higher taxes workers will pay.''
The story may be different, Mr. Cutler added, for retirees. Where now many employers pay for health insurance for retirees not yet eligible for Medicare, that may change.
Even if the billions of dollars in savings don't materialize, it could get them out of the messy business of deciding what type of health care their employees might have.
''We think that this process can ultimately yield some big savings for companies and take the responsibility and burden for health care out of their hands,'' Mr. Thompson said. Not what business lobbyists were pushing for in 2010, perhaps, but one more step away from work as a social service agency.
The Upshot, a New York Times venture, presents news, analysis and graphics about politics and policy.
URL: http://www.nytimes.com/2014/05/01/upshot/employer-sponsored-health-insurance-may-be-on-the-way-out.html
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GRAPHIC: PHOTO: Volunteers answered questions about the Affordable Care Act on March 29 in Miami, days before the enrollment deadline. As the law starts to take effect in the real world, many things will become clearer. (PHOTOGRAPH BY JOHN VAN BEEKUM FOR THE NEW YORK TIMES)
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July 3, 2013 Wednesday
The New Economics of Part-Time Employment
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 748 words
HIGHLIGHT: The Affordable Care Act will make part-time employment more attractive to many workers, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Even without employer penalties, part-time work will become more common next year and more expensive for taxpayers.
Much attention has been paid to people without health insurance, but for the purposes of understanding the entire labor market we must acknowledge that the uninsured are a minority of the population. Most of the work force has health insurance through full-time employment or through a spouse's employment.
Part-time employment rarely includes health benefits. The lack of health benefits and the lower pay for part-time work have traditionally discouraged people from taking part-time jobs rather than full-time jobs, but both of those attributes of part-time jobs are about to change.
Beginning next year, the Affordable Care Act will subsidize the health expenses for non-elderly families with income of 100 to 400 percent of the federal poverty line (about half of the non-elderly population has incomes in that range), but only if they are not offered health insurance through an employer. In other words, the new subsidies will not be available to most of those who do full-time work.
Because part-time workers will be eligible for the subsidies except in the rare instances in which their employer covers them, full-time work will no longer carry the advantage of access to health insurance. That by itself will encourage more people to seek part-time work.
Moreover, the subsidies will many times be generous enough that workers can make as much money in a part-time position as in a full-time one. The table below illustrates what may happen.
The left column of the table shows the economics of a full-time position (40 hours a week). Between employer health insurance premiums and the employee paycheck, this position costs the employer $56,000 a year, or about $28 an hour. The full-time employee's pay after his portion of health insurance premiums are withheld is $42,000.
Although covered by health insurance, the employee and his family incur $3,000 in additional health costs because of health insurance deductibles, co-payments and so on ($3,000 is typical for a family of four with a comprehensive health plan). The employee also has work expenses for commuting and child care, which I assume to be $100 a week when working full time.
The part-time column of the table shows a part-time position with the same employer cost per hour: $28. Because the position is part-time (only 30 hours a week), the annual employer cost is $42,000. All of the $42,000 consists of cash compensation for the employee, because the part-time position does not include health insurance.
The part-time employee has to pay for his own health insurance, but the new law limits his premiums to $2,149 (the new law pays the other $12,658 from the United States Treasury) and limits his out-of-pocket health costs to $2,193 (the new law pays the other $2,907; by design the new law increases deductibles and co-payments but uses subsidies to offset those increases for low- and middle-income families).
After work expenses ($75 a week for part-time employment) and health expenses, the part-time position pays $33,908: almost exactly the same as the full-time position's $34,000.
By taking a part-time position, the employee can have comprehensive health insurance coverage and make almost the same money as he would in a full-time position. Thus the two traditional deterrents to part-time employment are disappearing. In effect, the new subsidies totaling almost $16,000 offset, from the point of view of employers and their employees, the loss of production that occurs from working 30 hours a week rather than 40.
None of the above relates to the employer penalties associated with the new law, because the employers covered by my example avoid the penalty by continuing to offer comprehensive insurance to full-time employees. Those penalties create yet another set of reasons that part-time employment will become more common next year.
Shifts from full-time to part-time work will be remarkably more attractive for employers and employees than they used to be, and taxpayers will be picking up the tab.
What Job-Sharing Brings
Health Reform, the Reward to Work and Massachusetts
Older Workers Could Benefit if Companies Drop Insurance
Putting Off the Employer Mandate
Confusing the Public on the Affordable Care Act
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December 28, 2016 Wednesday 00:00 EST
How Donald Trump's Health Secretary Pick Endangers Women;
Op-Ed Contributors
BYLINE: ALLISON K. HOFFMAN and JILL R. HORWITZ
SECTION: OPINION
LENGTH: 933 words
HIGHLIGHT: Tom Price is likely to go after Obamacare's contraception-coverage requirement.
LOS ANGELES - With the selection of Representative Tom Price as secretary of health and human services, President-elect Donald J. Trump has taken a giant step toward undermining the health of American women.
It is regrettable, but not surprising, that Mr. Trump has nominated a strident opponent of abortion. It is also no surprise that Mr. Price, an orthopedic surgeon from Georgia, earned a zero rating from Planned Parenthood, an organization he'd like to defund, despite its role in providing preventive health services.
What may jolt even those who supported Mr. Trump is the extremity of Mr. Price's views on women's health. In Congress, he opposed a law that would protect women in Washington, D.C., from employment discrimination based on their decision to use birth control or have an abortion. He was a co-sponsor of legislation that would have defined life as beginningatconception, inviting arguments that common forms of birth control constitute a murder weapon.
So far, critics of Mr. Price's nomination have focused on his plans to abolish the Affordable Care Act. While that is unlikely to happen, the program's provisions for contraception and other services that women disproportionately use will be early and easy targets. Family planning services have long been a focus of Republican ire, and since the requirement to cover them appears in an administrative rule, rather than in a statute, Mr. Price's agency could overturn it by issuing a countervailing rule.
Family planning services are part of Obamacare's preventive care strategy. The law requires virtually all insurance plans to cover preventive health services like immunization and blood-pressure screening, depression and other health problems. It also forbids charging fees beyond the premiums - co-payments, coinsurance or deductibles - for this care.
Responding to evidence that health plans did not sufficiently take into account women's unique health needs, the law included preventive care for women on this list of required coverage. But instead of listing every covered service in the act itself, the law left that task to regulators in the Department of Health and Human Services. They, in turn, relied on a study based on a review by the Institute of Medicine (now the National Academy of Medicine) that recommended several categories of services: well-woman visits, screening for gestational diabetes, counseling for sexually transmitted infections, breast-feeding support, screening and counseling for domestic violence, and - most at risk of repeal now - contraceptive methods and counseling.
Recognizing that contraceptive services is a sensitive cultural and political issue, the Obama administration exempted houses of worship from the coverage requirement and created an accommodation for religious nonprofits. This requirement spurred litigation that ended up in the Supreme Court twice and resulted in some for-profit businesses' being able to opt out of the requirement, too.
Such care goes beyond reproductive health. The only doctor many women see regularly is a gynecologist, and in 35 states OB/GYNs can be a woman's Medicaidprimary care provider.
Moreover, 62 percent of all women of reproductive age use a contraceptive method, and 99 percent of women ages 15 to 44 who have ever had sexual intercourse have used at least one contraceptive method. In contrast, only 18percent of people between the ages of 18 and 64 visit an emergency room at least once each year. Yet no one doubts the importance of emergency coverage.
Obamacare did not invent the use of legal mandates to cover contraception. Before its enactment, 28 states required contraception coverage, and 85 percent of large employers provided it. The United States Equal Employment Opportunity Commission declared in 2000 that any health plan that covered drugs, devices and preventive care but that did not cover contraceptives violated the Pregnancy Discrimination Act.
So even if the new health secretary were to repeal the law's contraceptive coverage requirement, many insurance plans would still cover it. But state contraceptive coverage mandates don't reach everyone, and they don't address costs. Women in the 22 states without a mandate or working for the employers that did not cover contraception before the Affordable Care Act would have to pay the full cost on their own.
Women know what is at stake. That is why they have been rushing to see their doctors and to fill prescriptions before Mr. Trump takes office in January.
Paradoxically, cutting women's health care services is contrary to Republican goals. House Speaker Paul D. Ryan's health plan states, "Prevention requires efforts and investments today that are expected to provide long-term cost savings and other benefits." That is exactly what covering contraception does: provide women significant benefits to their health and socioeconomic status, while in many cases saving money for the health care system over all. Voters understand this. A majority of people, including two-thirds of women, support private health plans' covering the full cost of birth control.
Mr. Trump himself has said, America needs "a patient-centered health care system that promotes choice, quality and affordability." Women will be better off if the president-elect and his health and human services secretary follow this advice.
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Allison K. Hoffman and Jill R. Horwitz are professors of law at the University of California, Los Angeles.
DRAWING (DRAWING BY SALLY DENG)
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December 1, 2016 Thursday
Late Edition - Final
Why Indiana's Strict Medicaid Rules Could Spread
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; PUBLIC HEALTH; Pg. 23
LENGTH: 1011 words
In most of the United States, anyone poor enough to qualify for Medicaid simply receives whatever care doctors recommend at minimal cost. But many Medicaid enrollees in Indiana can't get full benefits unless they pay monthly premiums, and some who fail to pay can be shut out of coverage entirely for six months. If they go to the emergency room too often, they have to pay a fee.
These provisions were unprecedented departures for the program last year, and they were negotiated with federal health officials by Seema Verma, a consultant, on behalf of Gov. Mike Pence, now the vice president-elect. This week Donald J. Trump chose Ms. Verma to lead the Centers for Medicare and Medicaid Services, the influential agency inside the Department of Health and Human Services that oversees Medicare, Medicaid and the Obamacare insurance markets.
It is not clear what Ms. Verma may have planned for Medicare, a fully federal program that covers millions of older Americans and that usually makes up most of the administrator's job. Administrators of the agency typically come with some Medicare experience, and Ms. Verma appears to have little.
Her policy priorities for Medicaid are much clearer. Mr. Trump and congressional Republicans have vowed to repeal the Affordable Care Act, and to create new systems for providing health insurance to low and middle-income Americans. But even without legislation, the executive branch can do a lot to reshape existing programs by giving states more power. Ms. Verma's nomination suggests that the administration will become much more enthusiastic about approving novel Medicaid policies like those adopted in Indiana.
The Healthy Indiana Plan, as it's known, ''has been successful in meeting its policy objectives, but it also continues to demonstrate the potential for consumer-driven health care as an alternative to the traditional Medicaid model,'' Ms. Verma wrote in an article in the journal Health Affairs this summer, arguing that other states should adopt its provisions. (An employee of her consulting firm said Ms. Verma was not doing interviews or answering questions.)
The Medicaid statute allows states to throw out many, but not all, program rules to test whether they can deliver better care to Medicaid patients at a similar cost. The bright lines about which rules can be waived are often decided in court.
The Obama administration has been open to new ideas in Medicaid, in part because it has wanted to encourage Republican-led states to expand coverage to more of their residents. It has allowed major policy experiments in Arkansas and Iowa, but the Indiana plan pushed the furthest in requiring beneficiaries to spend their own money and follow complex rules to continue receiving full benefits.
Other changes to Medicaid long favored by Republican state officials, like requirements that applicants work to obtain benefits, could also be approved. The Obama administration has argued that such requirements violate the Medicaid statute.
Republican state officials argue that such rules help beneficiaries take a greater stake in their own health and help them learn the value of their benefits.
''When things aren't completely free, people begin to make more careful decisions about how and how much to consume,'' said Mitch Daniels, the former Indiana governor, who worked with Ms. Verma on an early version of the plan. Mr. Daniels, now the president of Purdue University, praised her as an ''indispensible technician'' for her efforts in devising the proposal.
Analysts have criticized the Indiana program, saying that there hasn't been good evidence that beneficiaries understood the incentive structure or changed their behavior because of it. They have also raised concerns that the program is complex and hard to manage -- that the cost of collecting small premiums exceeds the revenue the state receives. Judith Solomon, the vice president for health policy at the left-leaning Center on Budget and Policy Priorities, said the state had not cooperated with efforts to independently evaluate the program.
At the Centers for Medicare and Medicaid Services, Ms. Verma could also encourage large changes in middle-class coverage. A provision in the Affordable Care Act allows states to replace traditional Medicaid and the Obamacare insurance marketplaces with a different system if it can demonstrate that the plan would cover a similar number of people at a similar cost. The provision was envisioned as a way to allow liberal states to pursue single-payer systems. But health policy experts believe it could also be used to reshape many of the Affordable Care Act's insurance market rules.
''The Affordable Care Act really federalized the health insurance market, so now we can decentralize that again, bring that authority back to the states in determining what benefits are,'' said Dennis Smith, a former federal director of Medicaid in the Bush administration, who has also run the Wisconsin Medicaid program. He is now working for the Medicaid agency in Arkansas.
Other Medicaid experts worry about new barriers to health care, if the Trump administration approves plans that Obama administration officials have blocked.
''We can expect to see far-reaching changes contemplated for Medicaid that will erect many more barriers to coverage -- and very punitive barriers,'' said Joan Alker, the executive director of the Center for Children and Families at Georgetown University, in an email. ''For example, forcing people to remain uninsured for up to year if they miss a paperwork deadline or a premium payment, even though we know that conditions like mental illness or homelessness -- or something more simple like a notice getting lost in the mail -- may explain the missed deadline.''
But experts across the political spectrum agree: Ms. Verma's appointment will probably usher in a new era of state flexibility in health care.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
URL: http://www.nytimes.com/2016/12/01/upshot/a-trump-pick-and-why-indianas-strict-medicaid-rules-could-spread.html
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GRAPHIC: PHOTO: Seema Verma in New York recently. Donald J. Trump selected her to run the Centers for Medicare and Medicaid Services. (PHOTOGRAPH BY DREW ANGERER/GETTY IMAGES)
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(Fiscal Crisis)
October 1, 2013 Tuesday
Republicans and Democrats Look for Compromise
BYLINE: Jeremy W. Peters
SECTION: US; politics
LENGTH: 246 words
HIGHLIGHT: Some ideas were floated that members of both parties hoped would lead to a deal.
With the government entering its first day of the shutdown, Republicans and Democrats were beginning to float ideas that they hoped would lead to a compromise.
"We can work on something, I believe, on the medical device tax," Senator Richard J. Durbin of Illinois, the No. 2 Democrat, said on CNN.
The tax, which helps pay for President Obama's health care overhaul, has been a source of contention in both parties. House Republicans recently included a repeal as part of a larger package of demands that the Senate rejected on Monday.
Though Democrats have repeatedly insisted that they would not accept any budget deal that contains extraneous policy provisions - like the delays and defunding of the Affordable Care Act that Republicans have sought - Mr. Durbin's suggestion seemed to open the door slightly.
He did have a caveat: that the revenue from the so-called medical device tax be replaced if repealed.
At the same time, Senator Rand Paul, Republican of Kentucky, suggested that Congress pass a one-week budget that would allow government operations to continue while Democrats and Republicans talked. "Maybe we can work this thing out," he said on CNN.
But Senator Harry Reid, the majority leader, has so far rejected that approach.
Senate Rejects House Bill and Sends It Back
Utah Senator Causes Uproar Among House Republicans
Reid Rejects Negotiation on Budget Bill
House Passes Another Budget Bill Delaying Health Law
Senate Democrats Ready to Reject House Bill Immediately
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(Fiscal Crisis)
September 30, 2013 Monday
House Passes Another Budget Bill Delaying Health Law
BYLINE: Jonathan Weisman
SECTION: US
LENGTH: 200 words
HIGHLIGHT: With hours to go before the federal government runs out of money, the House on Monday night passed its latest bill to link further government financing to a weakening of President Obama’s health care law.
With hours to go before the federal government runs out of money, the House on Monday night passed its latest bill to link further government financing to a weakening of President Obama's health care law.
With the 228-201 vote, the House effectively made its last offer before a government shutdown at midnight. The bill demands a one-year delay in the health care law's requirement that individuals buy health insurance, and denies federal subsidies to members of Congress, Capitol Hill staff, executive branch appointees, White House staff, the president and the vice president, who would be forced to purchase their health insurance on the Affordable Care Act's new insurance exchanges.
Senate Democratic leaders announced they would immediately take up the spending bill, strip out the health care language and send it back to the House free of policy prescriptions. And with that, time would likely be out, and large portions of the government would be shut down.
Obama Says He Isn't Resigned to a Shutdown
Polls Show a More Negative View of G.O.P. Over Shutdown
House May Consider Short-Term Financing Measure
Boehner Shows No Signs of Backing Down
Senate Democrats Ready to Reject House Bill Immediately
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The New York Times
March 12, 2014 Wednesday
Late Edition - Final
Victory in Florida Race Bolsters Midterm Hopes for Republicans
BYLINE: By LIZETTE ALVAREZ; Arielle Stevenson contributed reporting from Largo, Fla., and Jonathan Martin from Washington.
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1226 words
CLEARWATER, Fla. -- In a major victory for Republicans in the battle for control of Congress, David Jolly, a former lobbyist, narrowly won a special election for a House seat on Tuesday in a hotly contested swing district, giving the party an expensive triumph in its fight against President Obama's health care plan.
After months of diligent courting by the three candidates and a $9 million barrage of political advertising by outside groups, voters in Pinellas County chose Mr. Jolly over Alex Sink, a Democrat and his main rival. Mr. Jolly won 48.4 percent of the vote and Ms. Sink received 46.5 percent. A third candidate, Lucas Overby, a Libertarian, won 4.8 percent.
It was a disappointing defeat for Ms. Sink and the Democratic Party, which had worked arduously to try to claim the longtime Republican seat.
Taking the stage to thunderous applause after his victory, a beaming Mr. Jolly, 41, said he would work across party lines to best represent the district.
''I did not run for Congress to advance Washington, I ran for Congress to advance Pinellas County,'' Mr. Jolly said. ''I seek to work with everybody. Know this: That does not mean resigning my convictions that we stand for, that brought us here tonight.''
The victory will embolden Republicans as they head into the midterm election and bolster their message -- that the nation disapproves of the Affordable Care Act and Mr. Obama's leadership.
''Tonight, one of Nancy Pelosi's most prized candidates was ultimately brought down because of her unwavering support for Obamacare, and that should be a loud warning for other Democrats running coast to coast,'' said Representative Greg Walden of Oregon, who is chairman of the National Republican Congressional Committee, referring to the House Democratic leader.
For Democrats, the loss is a significant blow to morale. Ms. Sink, 65, a moderate who lost her race for governor in 2010, is a well-known party figure and ran a well-organized campaign awash in donations and buoyed by millions of dollars of outside spending.
Even before the loss, Democrats were playing down a possible defeat, saying the mostly white, Republican-leaning district, packed with many older voters, was going to be a challenge for them.
''Republican special-interest groups poured in millions to hold on to a Republican congressional district that they've comfortably held for nearly 60 years,'' said Representative Debbie Wasserman Schultz of Florida, the chairwoman of the Democratic National Committee, after Ms. Sink's loss. By focusing greatly on repealing the Affordable Care Act, she said, ''Republicans fell short of their normal margin in this district.''
It is the first time in more than 40 years that the congressional district will be overseen by someone other than Representative C. W. Bill Young, a Republican who died in October, setting off the scramble for the job.
But for some voters, Mr. Jolly was the closest thing to Mr. Young -- for years he served as one of Mr. Young's senior aides and general counsel.
A tossup until the end, the race was largely commandeered by national political organizations waging a proxy battle over issues like the Affordable Care Act and Social Security. In countless ads, Republicans trumpeted Ms. Sink's support of the health care plan and lashed her to Mr. Obama and Ms. Pelosi. Democrats repeatedly accused Mr. Jolly of wanting to privatize Social Security.
But despite the victory, political analysts have said that the results of one House special election, no matter how close, seldom transcend state boundaries. Republican and Democratic groups poured record-setting sums into the race, raising its national profile and importance.
Outside groups like the U.S. Chamber of Commerce and the House Majority PAC, a Democratic group, spent more than $9 million on mostly negative television ads, robocalls and mailings devoid of nuance. Taking into account money raised by the candidates, total spending in the race hit $12 million, a staggering amount for a House seat in a special election.
Ms. Sink, who was the pick of the national Democratic Party, raised far more than Mr. Jolly, who faced a January primary and struggled to bring in checks. But outside Republican groups stepped in to level the playing field, spending considerably more in political advertisements than Democrats.
The race also drew the endorsements or appearances of marquee politicians from both parties, including former President Bill Clinton, Vice President Joseph R. Biden Jr., former Gov. Jeb Bush and Senator Rand Paul of Kentucky.
The Gulf Coast district, always a centerpiece in national elections because of its many independent voters and a nearly equal number of Democrats and Republicans, is in Pinellas County, and it includes much of St. Petersburg.
In a district used to being pounded with political ads, the barrage during this election left many voters feeling particularly irate. William Mosteller, a Democrat who cast his ballot in Largo, said he voted for Mr. Overby, in part because the ads and phones calls worked against Ms. Sink.
''I watched the debate and Overby was the only one with any sense,'' Mr. Mosteller said. ''I'm a Democrat and I've been bombarded by Alex Sink so much, the phone calls have been six, seven a day. It drove me nuts.''
Republicans typically benefit from special elections because they turn out to vote in larger numbers. On Tuesday, general turnout was 39 percent and more than 186,000 votes were cast. The majority were absentee ballots, which also generally favor Republicans. Ms. Sink tried to counter that edge with a pointed early voting effort but fell short.
In a brief concession speech, Ms. Sink said she was disappointed.
''I don't know what the future holds, but I will do what I always have done, which is to serve my community,'' she said.
Ms. Sink, a former bank executive who was elected in 2006 as Florida's chief financial officer, had an early advantage in the race: Democrats cleared the field for her. A moderate with a business background, she ran as someone eager to set aside ideology to end legislative gridlock in Washington.
Susan Demers, a professor at St. Petersburg College, said that while she voted for Ms. Sink, her recent move to the county gave her pause.
''It's a very disturbing election because on the one hand, Sink did not live in this district before,'' Ms. Demers said. ''On the other hand, I really felt like Dave Jolly was a lobbyist and that's very upsetting to me. I didn't see enough of Lucas Overby to make any judgment. So really, there were no good solutions here, for me.''
Still, Mr. Jolly, polished on the stump, proved a formidable opponent. He campaigned as Mr. Young's successor, and he recently tacked toward the right on issues like military intervention and abortion, saying he would support the repeal of Roe v. Wade.
And while underscoring that he would leave Social Security untouched for those who have paid in for 10 years, Mr. Jolly said all options, including privatizing the program, should be considered for younger workers. Ms. Sink and outside groups pilloried him over this position, as well as for his work as a lobbyist.
On Tuesday after his victory, Mr. Jolly, who had been critical of the blitz of negative ads, delivered another bit of welcome news to his supporters.
''I've got very good news tonight,'' he said, ''no more commercials.''
URL: http://www.nytimes.com/2014/03/12/us/politics/florida-votes-in-sink-jolly-house-race.html
LOAD-DATE: March 12, 2014
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GRAPHIC: PHOTO: David Jolly, who won a special election, took the stage on Tuesday to thank his supporters. (PHOTOGRAPH BY ANDY JONES/THE TAMPA TRIBUNE, VIA ASSOCIATED PRESS) (A16)
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(The Caucus)
March 19, 2012 Monday
Health Care Debate Returns With Intensity
BYLINE: MICHAEL D. SHEAR
SECTION: US; politics
LENGTH: 604 words
HIGHLIGHT: The health care reform law's two-year anniversary and Supreme Court arguments on its constitutionality will push the subject to the front of political agenda in the coming weeks.
For months, Mitt Romney has tried to deflect attention from his rivals' accusations that his health care plan was the inspiration for President Obama's overhaul. That task will be harder in the coming days.
This week is the two-year anniversary of Mr. Obama's health care law, and Republicans in Washington are planning to celebrate with a series of attacks. Next week, the Supreme Court will hear three days of arguments about whether the law is constitutional. The hoopla will be enormous.
The string of events will serve to push health care to the front of the public and political agenda - a development that is bound to embolden Mr. Romney's Republican rivals as they seek to undermine his march toward the presidential nomination.
Here is a guide to the health care hullabaloo in Washington:
The Background
Mr. Obama signed the Affordable Care Act - Republicans call it "Obamacare" - on March 23, 2010. It quickly became Example No. 1 for Republicans who argue that Mr. Obama is a big-government president who dreams of European-style socialism.
The Republican National Committee is promising to spend this week making that case "across multimedia platforms" and with "surrogates to drive the message on the national, state and local levels."
That will mean new opportunities for Rick Santorum and other Republicans to argue that Mr. Romney's health care plan was similar to what Mr. Obama put in place. On Friday, Kenneth T. Cuccinelli II, the Virginia attorney general, who has been waging a legal battle against the Affordable Care Act, said Republicans would be "effectively giving up the issue" of health care if they nominated Mr. Romney.
The Supreme Court
Next Monday, the Supreme Court will begin three days of oral arguments about whether the law's requirement that individuals buy insurance is unconstitutional. Both sides are gearing up for a political carnival outside the court building in Washington, as well as an extended debate that will play out on the cable news networks for the entire week.
Mr. Romney has repeatedly sought to draw clear distinctions between the plan he helped develop in Massachusetts and the kind of system he would support at the federal level. He has repeatedly said he would work to repeal the health care law if elected president.
But the fact is that Mr. Romney's state plan includes a measure requiring residents to buy insurance - a mandate - that is similar to the controversial provision at the heart of the challenge to Mr. Obama's law. That similarity will be fodder for cable news chatter as the networks seek to fill hours of analysis during the court's deliberations.
The Politics
In the meantime, Mr. Santorum and Newt Gingrich will be looking for ways to blunt Mr. Romney's momentum during this week's primaries in Illinois and Louisiana. Already, the Red White and Blue Fund, a "super PAC" backing Mr. Santorum, is running an ad in Illinois that attacks Mr. Romney on the health care issue.
"His health care takeover?" a narrator says in the ad. "The blueprint for Obamacare."
Mr. Santorum has been particularly critical of Mr. Romney on the issue, echoing Mr. Cuccinelli in saying that Mr. Romney would not be able to make the case against Mr. Obama's overhaul. In San Juan, P.R., over the weekend, Mr. Santorum said that "it's the equivalent of malpractice to nominate someone who gives away the most important issue in this race."
In an interview on Fox News last week, Mr. Romney said that "time and again, I've pointed out I'm not in favor of a health care plan that includes a national mandate." He will most likely have to repeat that line time and again in the coming days.
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January 20, 2017 Friday
Late Edition - Final
Republican Governors Seek Flexibility on Medicaid and Health Markets
BYLINE: By ABBY GOODNOUGH and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 819 words
WASHINGTON -- Republican governors pleaded with their fellow Republicans in Congress on Thursday to give states more control over both their Medicaid programs and their individual health insurance markets as lawmakers work with President-elect Donald J. Trump to replace the Affordable Care Act.
In town for Mr. Trump's inauguration, nine governors -- some who had expanded Medicaid under the law and some who had refused -- presented a united message: The Obama administration was too rigid in prescribing standards for Medicaid and private insurance coverage, and states need more power to set their own policies.
Many had already sent letters to Republican lawmakers urging them not to repeal the law before approving a replacement plan, and in comments after Thursday's session they focused on the details of what that replacement plan should be.
Given greater flexibility to set their own policies, several governors said, they would like to trim the number of people in Medicaid and the array of benefits offered in both the public program and private plans sold in the markets.
Yet at the same time, some, including John R. Kasich of Ohio and Asa Hutchinson of Arkansas, are lobbying to keep the generous federal financing provided by the law for expanding Medicaid. Mr. Hutchinson and Mr. Kasich have indicated they would like to reduce their Medicaid expansion populations while still having the federal government pay at least 90 percent of the cost of covering those who remain in the program.
Medicaid is the nation's largest government health insurance program, serving 22 percent of the population -- more than 70 million people -- at a cost of more than $500 billion a year. Before the Affordable Care Act, Medicaid recipients were largely children, parents, pregnant women and the elderly and disabled.
The law sought to change that by requiring every state to expand Medicaid to cover anyone with income up to 138 percent of the poverty level, or about $16,500 for a single adult. But the Supreme Court ruled that states could opt out of the provision, and many Republican-led states did so.
Still, 16 of the 31 states that expanded Medicaid under the law have Republican governors who now must decide whether to fight to preserve the size and scope of their programs in the Trump era.
The law offered a major financial enticement to lure states into expanding Medicaid: The federal government paid the entire cost for the first three years. Although states are beginning to pay a small portion of expansion costs this year, they are never required to pay more than 10 percent under the terms of the Affordable Care Act.
Some Republican governors have also expressed tentative support for Mr. Trump's proposal to change federal spending on Medicaid from an open-ended entitlement to a fixed annual amount, or block grant, for each state. Critics say block grants could result in states cutting people from the Medicaid rolls or reducing the services they get.
''The difference between a good block grant and a dangerous block grant is in the detail,'' Mr. Kasich wrote to congressional leaders recently.
Gov. Rick Scott of Florida told reporters outside the meeting room on Capitol Hill that he wanted the Trump administration to give him a set amount for each Medicaid beneficiary, but that the amounts should differ depending on the beneficiary's health needs. ''Individuals with different problems, there are different costs involved,'' he said.
Referring to the Department of Health and Human Services, Mr. Scott added, ''It was frustrating to me under Obamacare, where the H.H.S. didn't appear to have any interest in working with me. They said, 'You should do this and do it all 100 percent on my terms.'''
Mr. Hutchinson said he was ''very, very pleased'' with the meeting with senators, which also included Representative Greg Walden, Republican of Oregon and the chairman of the House Energy and Commerce Committee, which will play a large role in writing legislation to replace the Affordable Care Act. Governors held a separate meeting with Republican members of Mr. Walden's committee.
''Whenever you see senators and Chairman Walden taking notes on what governors are saying, that's a significant day for the principle of federalism,'' Mr. Hutchinson said.
In addition to Mr. Hutchinson, Mr. Kasich and Mr. Scott, the governors of Idaho, Iowa, Michigan, South Dakota, Texas and Utah attended the meeting.
In letters before the meeting, the governors also warned Congress not to do anything that would disrupt coverage for people who have gained it under the health law.
''We support a single repeal-and-replace package, but are concerned that a strategy to repeal now then later replace the A.C.A. could have serious consequences,'' Mr. Kasich wrote. He added that such consequences could include destabilizing the insurance markets and reversing recent coverage gains.
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October 31, 2016 Monday
Late Edition - Final
As Premiums Jump, Subsidies Are Imperfect Shield
BYLINE: By ROBERT PEAR; Michael D. Shear contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 1126 words
WASHINGTON -- Urging people to sign up for coverage under the Affordable Care Act, President Obama said last week that while premiums might be rising, most consumers need not worry. ''Premiums going up,'' he said, ''don't necessarily translate into higher premiums for people who are getting tax credits.''
Federal subsidies will generally grow with premiums, the administration says, even as rates soar 25 percent to 50 percent or more in some markets. ''Most people are going to be pleasantly surprised at just how affordable their options are,'' the president said.
But left unmentioned in the pitch to consumers are what economists and health policy experts describe as possible reasons to be concerned about rising premiums:
â- Higher subsidies mean higher costs for taxpayers.
â- Many people buying insurance on their own do not receive subsidies. And for many others, the subsidies are small.
â- Premium increases indicate the magnitude of cost increases for insurers. The continued increases in these costs help explain why the marketplace has been unstable and some insurers have pulled out.
''You should be concerned anytime prices go up rapidly,'' said Robert D. Reischauer, a former director of the Congressional Budget Office. ''This is increasing costs to the government.''
Moreover, federal officials say, publicity about rising sticker prices may discourage some people from seeking coverage in the marketplace, whose annual open enrollment period begins Tuesday. Research by the government and insurers suggests that many of the uninsured are unaware of the subsidies they may be able to obtain through the marketplace.
The Congressional Budget Office estimates that federal spending on premium subsidies will total $43 billion in the current fiscal year and $672 billion over the coming decade -- costs that could increase if premiums and subsidies continue to rise. Still, the subsidy costs are much less than the budget office originally predicted because enrollment is much lower and health costs have grown more slowly.
In his remarks last week on the Affordable Care Act, made in a conference call with thousands of supporters and health insurance counselors, Mr. Obama said that after subsidies are taken into account, ''more than seven in 10 consumers will be able to find a plan for less than $75 a month.''
But 15 percent of the 10 million people with marketplace coverage under the 2010 health law do not receive subsidies, mainly because their incomes are too high. And the administration estimates that 6.9 million people buy insurance on their own outside the marketplace, so they cannot obtain subsidies, which are available only through the exchanges. One-third of them might qualify for tax credits if they bought insurance through the exchange, federal officials said.
Emily Odza, a part-time librarian in Oakland, Calif., said the monthly premium for her Kaiser Permanente plan was rising next year to $900, from $800. Subsidies cover about half of the cost. She recently took a second part-time job.
''I worry most about the fact my income may rise slightly above the cutoff point,'' Ms. Odza said. ''If you want to earn as much as you can just to survive, the government takes away the subsidy.'' Financial aid becomes unavailable when an individual has income of more than $47,520 a year.
The Obama administration says people can usually avoid a big increase in premiums if they shop around. Ms. Odza called that advice ''totally maddening.''
''It took me several years to settle down with my doctors at Kaiser,'' she said. ''They expect me to switch every year to find the best price?''
Angela Gehm, a retired school administrator in Long Beach, Ind., said the increase in her premiums for 2017 outstripped the expected increase in her subsidy.
Ms. Gehm said she had recently received a notice from her insurer, Anthem Blue Cross and Blue Shield, saying the premium for her midlevel ''silver'' plan would rise to $1,007 a month next year, from $827 this year. The subsidy, $583 a month, will be the same, she said, so her cost will rise 74 percent, to $424 a month, from $244. It was not immediately clear how her subsidy had been calculated, but the subsidy is based on the cost of a reference, or benchmark, plan.
Ms. Gehm said she remained a staunch supporter of the Affordable Care Act. She said her views of the 2010 health law were informed by personal experience. She was treated for breast cancer in 2011-12 and benefited from a special insurance program created by the law for people with pre-existing conditions.
Two years before the law was enacted, she recalled, she sought insurance for herself and her son. He had Type 1 diabetes, she said, and the insurance company ''said flat-out, 'That's an automatic denial.''' The law now forbids such discrimination.
The White House says the cost of the subsidies is small compared with the overall savings of the health care law. Health costs are lower than expected, and ''we should use some of that money, some of those savings to now provide more tax credits for more middle-income families,'' Mr. Obama said in a recent speech in Miami.
George C. Halvorson, a former chief executive of the Kaiser Permanente health plan, said the rate increases were a reflection of the problems insurers faced. The premium, he said, reflects the average cost of care for an insured population.
''Every insurance company in the exchange has to figure out how to bring down that cost,'' he said. ''They can manage care better, pay less for each service or bring in a healthier population.''
Dr. David T. Feinberg, the president and chief executive of the Geisinger Health System, in Pennsylvania, said, ''We are going through bumpy waters, but I think the market is stabilizing.'' The Pennsylvania insurance commissioner has just approved rate increases averaging slightly more than 40 percent for Geisinger's health plan in 2017.
State insurance regulators have reviewed and approved most of the big rate increases taking effect in January. Insurers submitted data showing that they had lost tens of millions of dollars in the exchanges because customers were sicker than expected and, in some cases, dropped their coverage after receiving expensive care.
Many Democrats, including Mr. Obama and Hillary Clinton, who hopes to succeed him as president, want to increase subsidies to protect consumers against further increases in insurance costs. But some Democrats say that is not enough.
''Subsidies and more taxpayer dollars are not the only answer,'' said Jamie Court, the president of Consumer Watchdog, a liberal advocacy group. ''Insurance companies that get more subsidies will just keep asking for more subsidies, without controlling costs.''
URL: http://www.nytimes.com/2016/10/31/us/politics/affordable-health-care-premiums.html
LOAD-DATE: October 31, 2016
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GRAPHIC: PHOTO: A health insurance fair for the Affordable Care Act in San Francisco last year. This year's open enrollment begins on Tuesday. (PHOTOGRAPH BY JIM WILSON/THE NEW YORK TIMES)
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The New York Times
December 8, 2013 Sunday
National
Insurance Changes Raise Concerns for H.I.V. Patients
BYLINE: By EDGAR WALTERS.
ewalters@texastribune.org
SECTION: Section A; Column 0; National Desk; THE TEXAS TRIBUNE; Pg. 33A
LENGTH: 1063 words
When Dena Hughes learned about the Affordable Care Act's passage, she rejoiced.
Ms. Hughes, who has tested positive for H.I.V., the virus that causes AIDS, has struggled to find insurance coverage, because H.I.V. is considered a pre-existing condition. But even under the new law, Ms. Hughes said her care providers had advised her not to enroll in the federal health care exchange yet. It is unclear, they said, how the law will affect H.I.V. care when marketplace coverage begins Jan. 1.
''Right now we get good care, and I'm not interested in having my stuff all shifted around,'' she said from her Houston home.
Ms. Hughes and her husband, Daniel, also infected with H.I.V., receive some health coverage under the Ryan White Care Act, a federal health care program for H.I.V. and AIDS patients. Community advocates expected the Affordable Care Act to provide nearly universal health coverage for H.I.V. patients, freeing up funding from the Ryan White program to cover services beyond primary care.
But many H.I.V. patients in Texas live below the poverty line and are therefore ineligible for subsidies on the exchange. Add Texas' decision not to expand Medicaid to cover poor adults, and the bulk of low-income H.I.V. patients are missing out on expanded health coverage.
Mr. and Ms. Hughes, who have four dependent children, recently started a home repair business and do not know how much they will earn next year.
The stakes are high. If their income is below $31,590 -- the requirement for a family of six to receive tax subsidies on the federal exchange -- they will rank among the thousands of H.I.V.-positive Texans whose incomes are too low for subsidized private insurance but too high for Medicaid. Roughly 14,000 Texans with H.I.V. used assistance from the Ryan White program to pay for antiretroviral medication in 2011, while nearly 19,000 were not receiving any H.I.V.-related medical care, according to the Department of State Health Services.
Mr. Hughes receives medical care at Legacy Community Health Services, a federally qualified health center in Houston. Katy Caldwell, its executive director, said she had struggled to advise H.I.V. patients about the marketplace with certainty that their health plans would cover all their medications. ''You've got people on some complicated drug regimens that you want to make sure people stay on, and it's not as easy as it sounds,'' she said.
Referring to patients living below the poverty line, she added, ''One of the hard things to explain to people is you're actually too poor to get help.'' At Legacy, 58 percent of patients are uninsured.
Texas' Medicaid eligibility requirements are among the country's strictest. For a family of six, adults without a disability must earn less than $4,608 per year to qualify for coverage.
But Gov. Rick Perry has adamantly opposed Medicaid expansion, citing worries about the program's efficiency.
''The fact is that Medicaid is a broken system in need of fundamental reform,'' Lucy Nashed, a spokeswoman for Mr. Perry, said in an email. She added that ''Texas has a proven history of providing services and effective H.I.V. medications to H.I.V.-positive Texans through the H.I.V.-S.T.D. Program and the Texas H.I.V. Medication Program.''
Katherine Record, a senior fellow at Harvard Law School's Center for Health Law and Policy Innovation, directed a project that modeled how health reform would affect H.I.V. patients in Texas. She found that roughly 65 percent of Texans who received assistance from the AIDS Drug Assistance Program, a Ryan White program, would be eligible for Medicaid under the expansion.
By comparison, ''Pre-A.C.A., you could only qualify for Medicaid if you proved you were disabled, which pretty much meant having your H.I.V. progress to full-blown AIDS,'' she said.
For Santiago Estrada, a 53-year-old patient in Abilene, AIDS allowed him to enroll in Medicare, which covers his antiretroviral medication. He said the drugs alone would have cost him $2,000 per month out of pocket.
Mr. Estrada visits the Big Country AIDS Resources center in Abilene for care. He says the ''wraparound'' services the center provides with Ryan White funding, like assistance with nutrition and transportation, are paramount for his well-being.
Betty Sims, the center's executive director, says the Affordable Care Act could mean big changes for many of her clients' access to coverage. But for the 48 percent of her clients who live below the federal poverty line, most have never qualified for Medicaid ''and are really left out in the cold,'' she said.
Advocates say demand for transportation services ranks highly among the wraparound benefits that Ryan White money could assist with, if more H.I.V. patients had primary care coverage under the Affordable Care Act. For Ms. Sims's clinic and others that serve large rural populations, patients' lack of access to a vehicle is a significant obstacle to H.I.V. care. ''There's only one infectious disease specialist in the 19 counties we serve,'' Ms. Sims said. The center has partnered with infectious disease physicians at Texas Tech University to consult with patients electronically.
''The Ryan White services that we provide are going to continue to be needed here no matter whether people have access to insurance or not,'' Ms. Sims said.
One way states have sought to make the most of their Ryan White money under the new health law is to use the AIDS Drug Assistance Program funds to pay for H.I.V. patients' insurance premiums, rather than purchasing expensive drugs directly. Because the Affordable Care Act requires insurers to cover pre-existing conditions like H.I.V., ''in almost every case now it will be cost-effective'' to spend the money on H.I.V. patients' insurance premiums, even if they do not qualify for subsidies, said Ann Lefert, director of policy and health care access at the National Alliance of State and Territorial AIDS Directors.
Christine Mann, a spokeswoman for the Texas Department of State Health Services, said the agency was looking into such a measure.
Many advocates expect Texas to expand its Medicaid program eventually. But in the meantime, Ryan White funding will continue to shoulder primary care costs for the majority of impoverished Texans with H.I.V.
''They call it payer of last resort,'' Ms. Hughes said of that coverage. ''But for some people, it's the payer of first hope.''
URL: http://www.nytimes.com/2013/12/08/us/insurance-changes-raise-concerns-for-hiv-patients.html
LOAD-DATE: December 8, 2013
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GRAPHIC: PHOTOS: World AIDS Day in Houston. Texas' decision not to expand Medicaid to cover poor adults affects a large number of the state's H.I.V. patients.
Dena and Daniel Hughes at home in Houston. Their income may be too low for subsidized private insurance but too high for Medicaid. (PHOTOGRAPHS BY MICHAEL STRAVATO FOR THE TEXAS TRIBUNE)
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The New York Times
October 13, 2013 Sunday
National
For Aid Insuring Latinos, Groups Look Close to Home
BYLINE: By BECCA AARONSON.
baaronson@texastribune.org
SECTION: Section A; Column 0; National Desk; THE TEXAS TRIBUNE; Pg. 23A
LENGTH: 616 words
Though they make up roughly a third of the state's population, Latinos account for nearly two-thirds of the more than six million Texans without health insurance. But in the 13 days since a federal insurance marketplace aimed at helping the uninsured find coverage opened, health care advocates across the state have encountered common obstacles in getting Latinos registered, including limited access to computers and the lack of an e-mail address.
Advocates are developing community-based strategies to overcome these obstacles, and to ensure that Latinos do not miss out on insurance options available through the Affordable Care Act, which requires most people to carry coverage beginning in 2014.
One strategy is reliance on ''promotoras'' -- health counselors, often women, who provide education on health coverage options in Spanish-speaking populations.
''Just being bilingual isn't enough,'' said Frank Rodriguez, executive director and founder of the Latino Health Care Forum, which hopes to use promotoras to reach more than 50,000 uninsured people in the Austin area over the next six months. ''What we're doing is recruiting people from the community that know the norms and the customs of the people.''
Angelica Noyola, an Austin community activist hired as a promotora by the Latino Health Care Forum, said that when she asked her neighbors about the Affordable Care Act, she heard many false rumors: that anyone who works for a small company will be laid off, that the federal government will put people who do not have health insurance in jail.
''There's so much incorrect information out there,'' she said. ''It's quite scary to a lot of individuals.''
The online marketplace that the federal government began on Oct. 1 offers dozens of health plans and sliding-scale tax credits to help poor individuals and families buy coverage. Latinos account for roughly 1.7 million of the 2.8 million Texans estimated to be eligible for such tax credits, according to La Fe Policy Research and Education Center in San Antonio. There are also tax penalties for not buying health insurance.
Mr. Rodriguez said there are two daunting aspects of the federal marketplace for Latinos. He said it was difficult for Latinos, as with many people, to address the questions on taxes and projected income required to sign up for coverage. And he added that many Latinos are hesitant to commit to a major spending decision like health insurance.
''Affordability is a really subjective term for Latinos,'' Mr. Rodriguez said. That is why his organization's campaign to get them enrolled in the marketplace is relying on terms like ''security'' instead, he said.
Ms. Noyola said that many Latinos in Texas are living paycheck to paycheck, but that when it ''comes to health and each other, they pull together.''
She said many stand to benefit from the health plans offered in the marketplace because they will be financially protected and have access to preventive health services.
While some uninsured Latinos seek out assistance organically, Mr. Rodriguez said that in his experience, most will need to be contacted five to seven times -- by way of a phone call, a flier or a sit-down conversation -- to get them to enroll in the federal marketplace.
''The Latino community likes to have that face-to-face conversation when they're buying something as important as health care,'' said Arturo Aguila, an organizer for Border Interfaith in El Paso, which has created a similar community-based strategy to educate uninsured Latinos on the federal health overhaul.
With the help of local rabbis, priests and pastors, Border Interfaith has already held seven events to educate nearly 500 people on the Affordable Care Act.
URL: http://www.nytimes.com/2013/10/13/us/for-aid-insuring-latinos-groups-look-close-to-home.html
LOAD-DATE: October 13, 2013
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GRAPHIC: PHOTO: Jill Ramirez of the Latino Health Care Forum talked to Jesse Zavala about the Affordable Care Act in Austin. He said he knew little about the law. (PHOTOGRAPH BY SPENCER SELVIDGE FOR THE TEXAS TRIBUNE)
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The New York Times
March 9, 2017 Thursday
Late Edition - Final
Meager Support for Blend of Policy in Replacement Bill
BYLINE: By MARGOT SANGER-KATZ; Jennifer Steinhauer contributed reporting.
SECTION: Section A; Column 0; National Desk; PUBLIC HEALTH; Pg. 16
LENGTH: 996 words
Republicans in Congress are fond of calling Obamacare a death spiral of escalating costs and declining coverage. But their replacement plan could make those problems even worse.
Tuesday, the morning after two House committees released legislation that would replace the Affordable Care Act with the American Health Care Act, the plan received a tepid, even hostile reaction from many outside conservative groups and Republicans in Congress. The bill does less than many conservatives had hoped to open up the market for health insurance. And it still offers the kind of subsidies to middle-income people that they see as too generous. Mike Lee, a conservative senator from Utah, described the bill as ''not the Obamacare repeal bill we've been waiting for.'' (It perhaps goes without saying that it has been universally panned by Democrats.)
And here's why.
Republicans are constrained by their small majority in the Senate. Instead of passing a normal piece of legislation that could change the Affordable Care Act's many insurance regulations, they are limited to changes that can be accomplished through a technical budgetary maneuver, a reconciliation bill.
The result is likely to be higher prices for insurance, and fewer people with the ability to buy it. "The individual market seems less stable under this bill than under the Affordable Care Act,'' said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health research group. ''This bill comes across as a bit of a Frankenstein health bill because of the legislative strategy that's being used.''
Many conservative legislators would prefer a reprise of a 2015 bill that would have simply swept away much of Obamacare. But the current bill's drafters have felt political pressure from President Trump and their constituents to preserve some of the health law's coverage gains. Their efforts to preserve popular parts of the law and work within the special budget rules have led to the uneasy mix of policies in the bill.
The bill keeps many of the Affordable Care Act's rules for insurance companies that Republicans have decried for raising costs. Here's what stays.
â- The health law's rule that insurance companies must sell polices to the healthy and the sick at the same price.
â- Its rule that insurance companies can't limit the benefits they pay out in a year or a lifetime.
â- Its requirements that all plans cover 10 categories of benefits, including preventive health services without a co-payment, rehabilitation services and maternity care.
â- The law's caps on how much customers can be asked to pay for health care through deductibles and co-payments.
Those are popular provisions; they tend to make insurance coverage comprehensive but also somewhat costly. (The main reason that health insurance plans are expensive, of course, is because medical care is expensive, and the bill doesn't do anything about that either.) Because they all stay, the rest of the policy changes are built atop a chassis of health insurance products that cost what today's plans cost.
The bill effectively slashes subsidies that help many low-income people buy insurance, starting in 2020. A 60-year-old earning $20,000 in Lincoln, Neb., currently gets a subsidy of $18,470 to help her buy insurance, with extra subsidies to help her pay deductibles and co-payments, according to calculations made by Kaiser. Under the new legislation, she would get a subsidy of $4,000, and no help with cost sharing.
The bill also does away with Obamacare's requirement that people have insurance or pay a fine. That provision is unpopular, but it is seen as an important incentive for healthy people to buy insurance every year. The Congressional Budget Office has estimated that eliminating that provision would lead to premiums that are 20 to 25 percent higher, even without any cuts in subsidies.
As a counterweight, the bill does some things that would tend to stabilize prices. It gives states a big pot of money to help keep markets working. It allows insurance companies to charge higher prices to old customers and less to younger ones. That is not so good for our hypothetical 60-year-old in Nebraska, but might help lure some healthy 20-year-olds into the market who don't buy insurance now.
It also creates a new kind of financial incentive to buy insurance: People with a lapse in insurance coverage of more than a couple of months would have to pay a 30 percent higher price for their insurance when they re-enter the market. Advocates say this provision would get people to stay insured when they are healthy so they can afford coverage later. But some critics think it could backfire, since only sick people would be willing to pay the extra fee, which might not be enough to cover the extra cost of their care.
''The people who are going to take this gamble are going to be the healthiest,'' said Craig Garthwaite, the director of the health program at Northwestern's Kellogg School of Management. ''The only time you are going to get them into the market is if they get sick.''
Insurers have been vague so far on how they feel about this mix of policies. And the Congressional Budget Office, Washington's official scorekeeper, has not weighed in with estimates of how many people would be covered or what the bill would cost the federal government. But several health policy experts have said they believe the policy changes could result in the loss of health insurance for 10 million Americans or more.
Joe Antos, a scholar at the conservative American Enterprise Institute, said he sees some good ideas in the health bill, but estimated that it would cost 10 to 15 million people their insurance over the coming decade: ''It can't be a cohesive whole, because the things that can't be in a reconciliation bill aren't here.''
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URL: http://www.nytimes.com/2017/03/07/upshot/why-even-some-republicans-are-rejecting-the-replacement-bill.html
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GRAPHIC: PHOTO: People in Salt Lake City had questions for Senator Mike Lee about the health bill. He appears to have his doubts, too. (PHOTOGRAPH BY KIM RAFF FOR THE NEW YORK TIMES)
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July 24, 2014 Thursday
Late Edition - Final
Rulings on Health Law Could Deepen U.S. Divide
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; THE NEW HEALTH CARE; Pg. 3
LENGTH: 997 words
For decades, the United States has had a fragmented health policy. States called the shots on major elements of how health care and health insurance were financed and regulated. The result: a hodgepodge of coverage and a wide variance in health.
The Affordable Care Act was intended to help standardize important parts of that system, by imposing some common rules across the entire country and by providing federal financing to help residents in all states afford insurance coverage. But a series of court rulings on the law could make the differences among the states bigger than ever.
The law was devised to pump federal dollars into poorer states, where lots of residents were uninsured. Many tended to be Republican-leaning. But the court rulings, if upheld, could leave only the richer, Democratic states with the federal dollars and broad insurance coverage. States that opted out of optional portions of the law could see little improvement in coverage and even economic damage.
''It will be essentially health reform for blue states,'' said John Holahan, a health policy fellow at the Urban Institute, a research group.
On Tuesday, the United States Court of Appeals for the District of Columbia Circuit ruled that the law didn't allow the federal government to offer financial assistance to people buying insurance in states not running their own insurance marketplaces. That ruling is a long way from final -- a second federal court, considering the same issue, ruled to leave the subsidies untouched. If the Washington court's logic was endorsed by the Supreme Court, it could mean that millions of residents in 36 states would lose access to insurance through the A.C.A.
But even if the current cases fizzle, as some legal analysts expect, there is an existing red-state-blue-state fissure in insurance expansion under the Affordable Care Act.
Two years ago, the Supreme Court ruled that another key provision of the law, one that expanded the Medicaid insurance program to all low-income Americans around the country, would be optional for states. Now that the expansion is underway, existing disparities in rates of insurance have widened among the states. About half the states decided not to expand Medicaid. Recent surveys show that those states that did expand it have significantly reduced their uninsured population. An Urban Institute survey found that the uninsurance rate among adults under 65 had declined by 6.1 percentage points in states that expanded, compared with only 1.7 percentage points in those that didn't.
With the Medicaid decision and the D.C. Circuit decision, ''it really turns what was a national reform plan into a state-by-state reform,'' said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health care research group. ''It gives enormous power to states to decide whether major pieces of the Affordable Care Act go forward.''
There are 24 states that have not expanded Medicaid and that don't have state insurance exchanges. Fifteen states with state exchanges have expanded Medicaid. The remaining states are participating in one Obamacare program, but not the other.
The Medicaid expansion applied to families earning less than 135 percent of the federal poverty level, or about $16,000 a year for a single person. The insurance subsidies at the heart of the recent case apply to middle-income people who earn more -- up to 400 percent of the federal poverty level. The vast majority of people who bought Obamacare health insurance this year qualified for some level of subsidy, including an average of 87 percent of the people who signed up in the 36 states without their own marketplaces, according to an analysis from the health care industry consultants at Avalere Health.
Estimates from Kaiser suggest that most of the five million people who got subsidies in those states this year earned between twice and triple the poverty level, meaning they tend to be working families without access to employer coverage. These people probably could not easily afford the full price of an insurance policy. The Avalere analysis found that tax credits for the people who have already signed up for marketplace health plans paid for more than three-quarters of the cost of their premiums, on average.
Of course, many more people are expected to sign up for health insurance in the years ahead if the law proceeds unmodified. Kaiser estimates a total of nearly 13 million people who are legally eligible for subsidized insurance in the 36 states.
The elimination of subsidies would leave a group of states where residents ''would remain without many of the benefits of the Affordable Care Act,'' said Elizabeth Carpenter, a director at Avalere who wrote the report.
The loss of the subsidies could set in motion a cascade of consequences for those states. Obamacare requires people to obtain insurance if they can afford it, and fewer people will be subject to that requirement if the subsidies disappear. Taking away both the encouragement of subsidies and the penalties for remaining uninsured will most likely mean that only the sickest and most motivated people will keep buying insurance in those marketplaces. That, in turn, could drive up the cost of insurance and prompt insurers to stop selling their products there, making access to insurance even more difficult.
And the loss of insurance subsidies may also spell trouble for health care providers and the communities they serve. The Affordable Care Act paid for its generous subsidies in part by reducing payments it makes to hospitals. Hospitals took the deal because they calculated that all the new customers with insurance would help make up for the losses. The reduction in insured customers could mean big hits to those hospitals, many of which are major employers in their communities. The states in this category include some of the poorest in the nation.
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URL: http://www.nytimes.com/2014/07/24/upshot/two-americas-on-health-care-and-danger-of-further-division.html
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January 5, 2016 Tuesday
Conservative Group Sends G.O.P. Candidates a Letter Demanding Repeal of Obama's Health Care Law
BYLINE: CARL HULSE
SECTION: US; politics
LENGTH: 224 words
HIGHLIGHT: As the House prepares to send a repeal of the Affordable Care Act to President Obama, who will veto it, Heritage Action for America will send a letter to the Republican presidential candidates demanding they repeal it if they win the general election.
Conservative activists know they are not going to see a repeal of the Affordable Care Act signed into law with President Obama in the White House, even though the House is poised to send him legislation overturning the law on Wednesday.
But Heritage Action for America wants the current Republican field of presidential candidates to know what the expectations are should one of them win the general election. Suffice it to say, the group is not interested in hearing any more excuses about why a full repeal is not possible.
In a letter being sent on Tuesday to Republican presidential contenders, Heritage Action laid out three points on health care that they would like to see draw an "ironclad commitment" from the Republican field.
The group said the next Republican administration should agree to use all executive authority at its disposal to halt regulation of the insurance market under the new health law, ensure the new vice president presides over the Senate to guarantee "complete and full" repeal is achieved under special filibuster-proof rules, and then agree to sign a full repeal into law.
"America cannot afford another four more years of Obamacare," the letter concludes.
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March 27, 2012 Tuesday
Join Our Live Discussion About the Supreme Court Health Care Debate
BYLINE: THE NEW YORK TIMES
SECTION: US; politics
LENGTH: 196 words
HIGHLIGHT: At noon Eastern time on Thursday, Times reporters will be answering selected questions about the legal battle over the Patient Protection and Affordable Care Act.
At noon Eastern time on Thursday, Adam Liptak, the Supreme Court correspondent for The New York Times, and Reed Abelson, a reporter covering health care for the paper's Business Day section, will be answering readers' questions on Facebook about the legal battle over the Patient Protection and Affordable Care Act, President Obama's signature legislative achievement, which is being challenged in historic Supreme Court arguments.
The hourlong question-and-answer session will take place on The Times's Facebook page: facebook.com/nytimes.
Mr. Liptak will take legal questions, particularly on what he has witnessed at the Supreme Court this week. He has covered the court since 2008.
Ms. Abelson will answer questions about the vast reach of the law. She has been with The Times since 1995, and currently covers the health care business, focusing on how financial incentives affect the delivery of medical care.
Santorum and Foes Spar on Day of Health Care Hearing
Supreme Court to Release Same-Day Recordings of Health Care Arguments
Unions Urge Curtailment of 'Super PACs'
Santorum Plays Down Disagreement With Specter
In Michigan, Voters Question Romney's Conservative Credentials
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March 4, 2011 Friday
Late Edition - Final
Judge Who Ruled Against Health Care Overhaul Allows It to Proceed
BYLINE: By KEVIN SACK
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 826 words
A federal judge in Florida stayed his own ruling against the Obama health care law on Thursday, allowing the act to be carried out as the case progresses through the Courts of Appeal and on to the Supreme Court.
The judge, making evident his irritation with the Obama administration, sought to speed the process by conditioning the stay on the Justice Department's pursuit of an expedited appeal, which he ordered filed within seven days.
''The sooner this issue is finally decided by the Supreme Court, the better off the entire nation will be,'' wrote the judge, Roger Vinson of Federal District Court in Pensacola. ''And yet, it has been more than one month from the entry of my order and judgment and still the defendants have not filed their notice of appeal.''
The stay -- essentially a suspension of the judge's order pending appeals -- settles the confusion that arose after Judge Vinson ruled on Jan. 31 that a central provision of the law was unconstitutional, and that the rest of the law -- the Affordable Care Act -- must fall with it.
Judge Vinson had written that his ruling should be viewed as the ''functional equivalent'' of an injunction, which would typically stop the law in its tracks.
But the Obama administration did not immediately cease carrying out the law and, rather than seek a stay, asked the judge to clarify his ruling. States were unsure how to proceed, with some stopping all planning and others acting as if nothing had changed.
That began to change quickly with the issuance of Judge Vinson's stay on Thursday.
Gov. Sean Parnell of Alaska, a Republican who announced last month that his state would not put in effect the health law in light of Judge Vinson's ruling, said Thursday that ''our administration will treat the federal health care law as being in place.''
Judge Vinson is one of two federal judges who have ruled that Congress exceeded its constitutional authority to regulate interstate commerce when it enacted a law that requires most Americans to obtain health insurance (starting in 2014). The Pensacola case was brought by elected officials from 26 states, all but one of them Republicans, and by the National Federation of Independent Business, which represents small firms.
Only Judge Vinson has declared the entire act void, including provisions that have already taken effect, like requirements that insurers cover children regardless of pre-existing conditions. Three other federal judges, meanwhile, have upheld the law.
Judge Vinson wrote Thursday that his initial order ''was as clear and unambiguous as it could be'' and that the federal government had no right ''to basically ignore'' it.
He said he had expected the Justice Department, which represents the administration, to immediately seek a stay of his ruling. He said that in order ''to save time in this time-is-of-the-essence case,'' he would treat the government's motion to clarify as a request for a stay. And then he granted it.
In a 20-page order, Judge Vinson wrote that ''reasonable and intelligent people (and reasonable and intelligent jurists) can disagree'' about the constitutionality of the insurance requirement. The judge ruled that the act of not purchasing insurance is not an activity that can, under Supreme Court precedent, be penalized by Congress. Justice Department lawyers have countered that not buying insurance is an active decision, with significant implications for the health care market, that can therefore be regulated.
Because that legal question has not been addressed directly by the Supreme Court, Judge Vinson acknowledged that the government had some chance of prevailing on appeal, a primary requirement for a stay.
''It is likely that the Courts of Appeal will also reach divergent results and that, as most court watchers predict, the Supreme Court may eventually split on this issue as well,'' Judge Vinson wrote. ''Despite what partisans for or against the individual mandate might suggest, this litigation presents a question with some strong and compelling arguments on both sides.''
The judge also wrote that the confusion caused by enjoining the health care law would outweigh any potential harm to the states caused by its continuation.
''We appreciate the court's recognition of the enormous disruption that would have resulted if implementation of the Affordable Care Act was abruptly halted,'' said Tracy Schmaler, a spokeswoman for the Justice Department.
Ms. Schmaler said a request for an expedited appeal would be filed ''promptly'' with the Court of Appeals for the 11th Circuit in Atlanta. Appeals in other cases are already pending in two different courts, with oral arguments scheduled as early as May.
Attorney General Pam Bondi of Florida, the lead plaintiff in the Pensacola case, said in a statement that she was disappointed that Judge Vinson had granted the stay. But she said his insistence on an expedited appeal ensured ''that there will be no more stalling from the federal government.''
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LOAD-DATE: March 4, 2011
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GRAPHIC: PHOTO: Judge Roger Vinson ordered an appeal filed in seven days. (PHOTOGRAPH BY TONY GIBERSON/PENSACOLA NEWS JOURNAL)
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The New York Times
September 11, 2015 Friday
Late Edition - Final
House Hearing on Insurer Mega-Mergers Bares Health Care Industry Divide
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 865 words
WASHINGTON -- Doctors, hospitals and health insurance companies clashed Thursday over the merits of mergers planned by four of the five biggest insurers in the United States.
The confrontation came at a hearing of a House Judiciary subcommittee that is investigating competition in the industry and how it would be affected by mergers combining Aetna with Humana and Anthem with Cigna.
Daniel T. Durham, an executive vice president of America's Health Insurance Plans, a trade group for the industry, told Congress that the consolidation could promote competition and benefit consumers, achieving economies of scale that reduce costs.
Moreover, Mr. Durham said, insurers are trying to counter the ''harmful impact of consolidation among hospitals and other health care providers'' and what he called ''monopoly pricing'' by makers of some prescription drugs.
However, Thomas L. Greaney, an expert on health and antitrust law at St. Louis University, said he was skeptical of the argument that insurers had to merge to counter the market power of hospitals and doctors.
Professor Greaney likened giant insurers and hospital systems to sumo wrestlers. ''Experience suggests that a showdown between the sumo wrestlers may well result in a handshake rather than an honest wrestling match,'' he testified.
Even if a dominant insurer succeeds in bargaining successfully with providers, Mr. Greaney said, ''it has little incentive to pass along the savings to its policyholders.''
Witnesses from the American Hospital Association and the American Medical Association harshly criticized the proposed mergers.
''The Anthem-Cigna transaction threatens to reduce competition in at least 817 markets across the United States serving 45 million consumers,'' said Richard J. Pollack, the president of the hospital association.
Anthem operates Blue Cross and Blue Shield plans in a number of states, and Mr. Pollack said that Anthem's acquisition of Cigna could ''further entrench'' the dominant position of such Blue plans in many insurance markets.
Mr. Pollack assailed the proposed Aetna-Humana deal on other grounds, saying it would eliminate competition between the companies' Medicare Advantage plans.
More than 30 percent of the 55 million Medicare beneficiaries have enrolled in such private plans, attracted by the promise of extra benefits and lower costs.
Mr. Durham, the insurance industry representative, said that hospital mergers often led to substantial increases in hospital prices, and that those increases led to higher premiums.
In addition, he said, when hospitals buy physician groups, the doctors tend to charge more.
Mr. Pollack challenged those arguments. ''The annual growth in hospital prices has been low and declining,'' he said, and hospital clinics face competition from walk-in clinics at CVS, Walgreens and Walmart stores.
Dr. Barbara L. McAneny, a trustee of the American Medical Association, said that ''the concentration of market power among a handful of nationwide insurers'' could interfere with doctors' ability to care for patients.
The mergers, she said, could threaten the ''health and safety of American patients,'' and if the deals are consummated, ''there is simply no going back.''
The Justice Department is reviewing the deals to see if they would violate the Clayton Antitrust Act of 1914, which generally prohibits mergers and acquisitions if the effect ''may be substantially to lessen competition.''
At the hearing Thursday, House members expressed keen interest in the mergers, but their views did not appear to have crystallized into support or opposition.
They did split along party lines on a related question: whether the Affordable Care Act was driving consolidation in the insurance and hospital industries.
Representative Robert W. Goodlatte, Republican of Virginia and chairman of the House Judiciary Committee, said the 2010 law ''put in place a regulatory structure that stifled competition and instituted incentives for increased market consolidation.''
But Representative Hank Johnson, Democrat of Georgia, said: ''The Affordable Care Act is a reaction to, not a cause of, consolidation in the health care marketplace. Waves of consolidation among health care providers and insurers occurred long before the Affordable Care Act.''
Mr. Johnson said that competition among health plans in the new public insurance markets had held down premiums while increasing the number of choices available to consumers.
Dr. Scott Gottlieb, a resident fellow at the conservative American Enterprise Institute, who was a federal health official from 2003 to 2007, said, ''In the commercial market for private coverage, there's been a contraction in the number of carriers offering health plans.''
''Only about 50 new health carriers have entered the commercial market since 2008,'' Dr. Gottlieb said at the hearing. ''Half of these are the struggling not-for-profit co-op plans that the Affordable Care Act subsidizes. Around 40 health plans have left the market over this same stretch of time.''
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URL: http://www.nytimes.com/2015/09/11/us/house-hearing-on-insurers-mergers-exposes-health-care-industry-divide.html
LOAD-DATE: September 11, 2015
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GRAPHIC: PHOTO: Thomas L. Greaney, an expert on health and antitrust law, said Thursday he was skeptical insurer mergers would lower costs. (PHOTOGRAPH BY ZACH GIBSON/THE NEW YORK TIMES)
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January 21, 2017 Saturday 00:00 EST
The Republican Health Care Con;
Editorial
BYLINE: THE EDITORIAL BOARD
SECTION: OPINION; sunday
LENGTH: 765 words
HIGHLIGHT: Trumpcare could be so much worse than Obamacare that it would barely deserve the name insurance.
Republicans say the Affordable Care Act provides health insurance that manages to be both lousy and expensive. Whatever the flaws of these policies, the new Trump administration is trying to pull off a con by offering Americans coverage that is likely to be so much worse that it would barely deserve the name insurance. It would also leave many millions without the medical care they need.
This reality became increasingly clear when President Trump's choice to run the Department of Health and Human Services, Tom Price, testified before a Senate committee last week. He looked pained as he described the terrible predicament of people who earned around $30,000 to $50,000 a year and had to deny "themselves the kind of care that they need" because they had Obamacare policies with deductibles of $6,000 to $12,000. Yet, earlier in the same hearing, Mr. Price extolled the virtues of policies that would be woefully inadequate - policies that cover medical treatment only in catastrophic cases. Such policies often have deductibles of around $14,000 for family coverage. This is simple hypocrisy. Condemn the policy you don't like, propose something far worse as a replacement and claim that it is much better.
Mr. Price and Mr. Trump have recently said that their goal is to offer health care to many more people than are covered by the current health care law, which has driven the uninsured rate to historic lows. Mr. Trump went so far as to say he would provide "insurance for everybody" - something his press secretary, Sean Spicer, later walked back. But Mr. Price's testimony and the legislation he introduced in the House, where until recently he was the Budget Committee chairman, show that the new administration will make decent health care less affordable and less accessible for most people. And Mr. Trump was already trying to undo parts of the A.C.A. through an executive order on Friday, just hours after being sworn in.
At last week's confirmation hearing, Mr. Price suggested that Congress and the new administration could improve health care by expanding health savings accounts, in which people can put aside money, tax-free, to pay for out-of-pocket health costs in the future. But those accounts would not help families earning the median household income of $56,000 a year because these families would never be able to sock away enough money to, say, pay for cancer treatment or major surgery. These accounts would primarily benefit the wealthy, who want to shield more of their income from taxation and can easily afford to pay high out-of-pocket costs.
The best description of what Mr. Price stands for can be found in a bill he introduced in 2015, the Empowering Patients First Act. It would "empower" Americans by eliminating the health care law's expansion of Medicaid that has helped more than 10.7 million newly eligible people enroll in that government-run insurance program. It would also drastically cut subsidies that have helped 11.5 million people purchase private insurance on federal and state health exchanges. Under his bill, people buying insurance for themselves would get between $1,200 and $3,000 a year in subsidies, down from an average of $4,600 that people get now on HealthCare.gov. The bill would even get rid of the requirement that allows young people to stay on their parents' insurance policy until age 26, a provision that is widely popular. And it would hurt people who get insurance through their employers by setting a cap on how much of that expense businesses can claim as a deduction on their taxes. Experts say that over time this would encourage companies to stop offering health benefits to workers.
When it comes to health care, Mr. Price and other Republicans say their goal is to give people more choices. It is hard to argue against choice. But in the ideological world inhabited by Mr. Price, House Speaker Paul Ryan and many other Republicans, choice is often a euphemism for scrapping sensible regulations that protect people.
Some Americans might well be tempted by this far-right approach. They would have to pay less up front for these skeletal policies than they do now for comprehensive coverage. But over time, when people need health care to recover from accidents, treat diabetes, have a baby or battle addiction, they will be hit by overwhelming bills. The Trump administration seems perfectly willing to sell those people down the river with false promises.
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October 1, 2013 Tuesday
For Many, Personal Service Is More Helpful Than Web Site
BYLINE: Jon Hurdle
SECTION: US
LENGTH: 450 words
HIGHLIGHT: At the Spectrum Health Center in West Philadelphia, Pa., only four potential customers for the new health care marketplace had come through the doors by about 11:30 a.m. They were outnumbered by navigators, communications staff and reporters.
WEST PHILADELPHIA, Pa. - At the Spectrum Health Center here, only four potential customers for the new health care marketplace had come through the doors by about 11:30 a.m. They were outnumbered by navigators, communications staff and reporters.
One of the customers, Daniel Flynn, 28, was hoping to use the marketplace to find better coverage than he currently has in a plan that costs him $204 a month.
But if the exchange offered a plan with lower premiums, reduced deductibles or better coverage, that information wasn't immediately available because the federal government's Web site, healthcare.gov, was not accessible on one of a number of laptops set up in the Philadelphia center.
By 10:30 a.m. Eastern time, Mr. Flynn said he had tried to enter preliminary login information on the site but was unable to submit it, apparently because of the volume of requests that the site was receiving from around the country.
But working with Kyle Rouse, a "navigator" with the Health Federation of Philadelphia who was tasked with helping consumers, Mr. Flynn discovered that he would face maximum out-of-pocket expenses of $6,250 if he enrolled in a "bronze" level plan in the new marketplace. That would be significantly lower than the $10,000 he currently faces, in the first sign that the marketplace could offer him a better deal than the old system.
Mr. Flynn, who said he made about $33,000 a year, said he might end up paying the same premium as at present but was still hoping to find better coverage through the marketplace.
"I would potentially pay the same for a plan that's significantly better," he said.
Roderick Schichtel, 46, who is uninsured and unemployed, said he had come into the health center to find out more about getting coverage but learned he didn't qualify because his annual income of $6,000 to $7,000 was too low to get health insurance through the public exchange. Individuals with very low incomes are expected to apply for Medicaid coverage.
Working with a navigator, Mr. Schichtel said he obtained information in the form of printed material provided by the health center. He did not try to get on the government's Web site, which was still inaccessible to people in the Philadelphia center at 11:30 a.m.
Mr. Schichtel said he had arrived at the health center without any expectations that he would be able to get insurance through the exchange, and so was not disappointed. "I have been without health insurance for many years," he said.
At a Miami Health Center, Told to Come Back Another Day
Polls in Overtime on Affordable Care Act
A Scramble as Day 1 Approaches
Answers to Some Questions About Health Care Exchanges
In Debut, Affordable Care Web Site Gets Off to Rocky Start
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The New York Times
February 16, 2017 Thursday
Late Edition - Final
Trump's Big Opportunity to Reshape Federal Courts
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; PUBLIC HEALTH; Pg. 3
LENGTH: 713 words
If you want to keep your health insurance status a secret from the I.R.S., the Trump administration just made it a little easier.
The policy change, confirmed by the I.R.S. on Wednesday after elements were reported by the libertarian magazine Reason, does not do away with the Affordable Care Act's requirement that all Americans who can afford it obtain health insurance or pay a fine. But it might make it a little harder for the I.R.S. to figure out who is breaking the rules.
The I.R.S. recently notified tax preparers that it will not reject tax returns that omit information about whether a filer had health insurance during the previous year. That's actually a continuation of an informal Obama administration policy, but because of the way the decision was announced, it is likely to have broader effects on how many people report their insurance status to the government and how many people end up paying penalties for staying uninsured.
Mr. Trump signed an executive order on the day of his inauguration asking agencies to reduce burdens related to compliance with the health law. In its statement, the I.R.S. indicated that this policy was related to that instruction.
Tax returns include a line that asks people to indicate whether they had insurance for the entirety of the previous year. If they did, they can check a box. If not, they are asked to provide more detail: about how much coverage they had; whether they had been granted an exemption; or, if they owe penalties, how much.
Under the Obama administration, the I.R.S. would still process the tax return if a filer did not fill out this part of the return, but the policy was informal. Tax preparation software, used by individuals and professional tax preparers, essentially made it impossible to omit the section. The Obama administration had announced that it was ending its informal policy this year, and would begin rejecting returns that left off insurance information.
Under the new guidance from the Trump administration, that is changing, and the old policy is becoming more formal. Julie Miller, a spokeswoman for Intuit, which owns the personal tax preparation program TurboTax and provides software for tax preparers and accountants, said that the company would be changing its products on March 2 in response to the change. Currently, the software does not allow customers to complete a return without providing health insurance information. After the change, the health insurance portion of the return, known as Line 61, will remain part of the software, but customers will not get an alert if they leave it blank. As Reason reported, Drake Software, another company that provides programs for professional tax preparers, is making a similar change.
Even if it accepts returns with the section left blank, the I.R.S. can still review these returns, audit such filers or impose penalties. And on Wednesday the I.R.S. also clarified that it will continue to enforce the penalty. But the change may signal to some people that buying insurance is less important.
''While this announcement is consistent with the recent executive order, it is concerning to those who worry about stability in the A.C.A. marketplace,'' said Nicole Elliott, a partner at the law firm Holland and Knight, who was a senior director of operations for the Affordable Care Act at the I.R.S. during the Obama administration.
The change was announced on the same day that the Department of Health and Human Services released proposed regulations meant to stabilize the Affordable Care Act's marketplaces for individual insurance. Those new rules will mostly make it harder for sick people to sign up for insurance coverage only when they need it. Insurers have been asking for such changes; they argue that the pool of people buying Obamacare policies tends to be old and sick, making them expensive to insure. They have largely cheered the proposed rules.
But the tax change could cut the other way. The mandate to buy insurance was devised to bring healthy people into the insurance market, and a weaker mandate is likely to cause more such people to drop out.
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April 27, 2014 Sunday
Late Edition - Final
In Poorest States, Political Stigma Is Depressing Participation in Health Law
BYLINE: By JACKIE CALMES
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 1347 words
HUNTINGTON, W.Va. -- Inside the sleek hillside headquarters of Valley Health Systems, built with a grant from the health care law, two employees played an advertisement they had helped produce to promote the law's insurance coverage for young, working-class West Virginians.
The ads ran just over 100 times during the recent six-month enrollment period. But three conservative groups ran 12 times as many, to oppose the law and the local Democratic congressman who voted for it.
This is a disparity with consequences. Health professionals, state officials, social workers, insurance agents and others trying to make the law work for uninsured Americans say the partisan divisions and attack ads have depressed participation in some places. They say the law has been stigmatized for many who could benefit from it, especially in conservative states like West Virginia that have the poorest, most medically underserved populations but where President Obama and his signature initiative are hugely unpopular.
Steven L. Shattls, chief executive of Valley Health, a network of 28 health centers, said his organization would like to rerun its ad before November, when enrollment resumes. But he also conceded, ''We have limited resources.''
Republican candidates and the so-called super PACs supporting them have made assailing the Affordable Care Act their No. 1 issue for the midterm elections, and they are focusing their attacks in states with the most competitive Senate and House campaigns. In few places is that as evident as here in southern West Virginia, where Representative Nick J. Rahall II, a 19-term Democrat, is threatened as never before.
''We don't know what's going to happen once they pull out all the stops to trash Obamacare,'' Mr. Shattls said. ''We're nonpartisan here. We're just doing what we're funded to do, and that is to provide access'' to health care.
In the past week, 22 new television ads against the health care law and for Republican federal candidates ran in 14 states. Since last spring, 76 percent of the more than 38,000 Republican-sponsored television ads nationally, and 79 percent in West Virginia, have attacked the law, according to Kantar Media/CMAG, which tracks political advertising.
''Unless public opinion breaks decidedly in favor of the law or some other unexpected but powerful issue arises, Obamacare will remain the top issue in Republican House and Senate TV advertising for the duration of the cycle,'' said Elizabeth Wilner, senior vice president at Kantar Media.
While the evidence that such ads, and the partisan climate generally, have hindered sign-ups consists mainly of anecdotes, nearly everyone interviewed in West Virginia volunteered some.
''The controversy about Obamacare does seem to have interfered with people's ability to sort out the value of the marketplace for getting health insurance for themselves,'' said Dr. James B. Becker, associate professor of the Marshall University School of Medicine and medical director of the state's Medicaid program.
Other problems stymied the introduction of the law, notably the initially dysfunctional federal website. But the political polarization ''complicates our efforts to enroll people and to educate people about the Affordable Care Act, there's no question,'' said Perry Bryant, head of the advocacy group West Virginians for Affordable Health Care, based in Charleston, the capital.
''Literally, people thought there would be chips embedded in their bodies if they signed up for Obamacare,'' Mr. Bryant said.
Far to the east, at a branch of the Shenandoah Valley Medical System in Martinsburg, Sara R. Koontz, a social worker, said she had heard people express fears about chip implants as well as ''death panels'' as she sought to enroll uninsured residents. Some told her that they would rather pay a penalty than sign up for insurance, she said, and even people who did enroll paused in their excitement to ask, ''Wait -- this isn't that Obamacare, is it?''
Stoking such sentiments in order to rouse conservatives to vote is central to Republicans' hopes of not only keeping their House majority but perhaps recapturing the Senate. They are counting on West Virginia to help.
In the race to replace longtime Senator Jay Rockefeller, a Democrat and advocate of the health care law who is retiring, Representative Shelley Moore Capito, a Republican, is favored over the Democrat, Natalie E. Tennant, West Virginia's secretary of state. On her website, Ms. Capito solicits voters' stories about the ''disastrous'' law, while Ms. Tennant, echoing the mixed messages of many Democrats, acknowledges the law's problems but praises its benefits for women and children.
The more closely watched contest is the House race here in the state's southernmost, poorest district. Mr. Rahall is under attack both from Evan Jenkins, a state senator, and from the pro-Republican groups advertising on Mr. Jenkins's behalf.
Until recently, Mr. Jenkins was a Democrat, a member of Valley Health's board and executive director of the West Virginia State Medical Association, which has supported the Affordable Care Act. Now, as a Republican, he backs its repeal.
''Evan knows Obamacare is a mess,'' said an ad from the U.S. Chamber of Commerce, which blamed the law for lost jobs, dropped coverage and high premiums. An ad from the group Americans for Prosperity, backed by the conservative billionaires David H. and Charles G. Koch, denounced Mr. Rahall for supporting the law, saying it was ''going to hurt a lot of people.''
Many professionals here dispute such claims. ''It's working, and you can show it's working,'' Dr. Becker said.
He and other health care advocates call West Virginia a national success story in terms of the Affordable Care Act's expansion of Medicaid to more of the working poor. While 24 states have refused to expand Medicaid to those earning up to 138 percent of the federal poverty level, or $23,850 for a family of four, Gov. Earl Ray Tomblin, a Democrat, decided over Republican objections that the state -- with a population older and sicker than the national average -- would do so.
Nationwide, more people have signed up for private plans than for Medicaid, but the results are the opposite in West Virginia, where about 15 percent of residents -- 270,000 of 1.8 million -- lacked insurance when the law took effect. Initial sign-ups for Medicaid, about 115,000 since Oct. 1, are nearly double what actuaries projected, and roughly five times the number of people believed to have bought private plans from the one insurer in West Virginia's marketplace, Highmark Blue Cross Blue Shield. An estimated 20,000 to 25,000 people enrolled in private coverage, fewer than predicted.
State, industry and consumer representatives generally agree on why West Virginia was so successful with Medicaid yet fell short in the private marketplace.
Much of it has to do with the process of reaching out to the uninsured. For Medicaid, state agencies coordinated to write to 114,000 people already receiving nutrition assistance, to seek their authorization for the state to determine whether they qualified for the expanded health benefits. The state followed up with another letter and phone calls. No such outreach was possible to pitch private insurance to people not on public-benefit rolls, and the governor -- concerned, insiders say, about being too closely identified with the health care law -- turned down federal aid for a marketing campaign.
Many of the uninsured were also deterred from participating by cultural factors: unfamiliarity with insurance, computer illiteracy, Appalachian isolation and, most of all, cost. But also at play was hostility to Mr. Obama.
''The president is definitely unpopular here,'' said Jeremiah Samples, assistant to the secretary at the State Department of Health and Human Resources. ''I would not discount it as a factor; I have heard folks discuss it.'' He added, ''There is perhaps a lot attributed to the A.C.A. that is not actuarially accurate.''
''I worry,'' Mr. Samples said, ''about people not understanding what their options are.''
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Dr. Charles Beckett removed a tooth at a Valley Health Systems clinic in Huntington, W.Va. (PHOTOGRAPHS BY LUKE SHARRETT FOR THE NEW YORK TIMES) (A20)
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February 18, 2017 Saturday
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Wrath Awaits G.O.P. Leaders During Recess
BYLINE: By KATE ZERNIKE and ALEXANDER BURNS
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1627 words
As Republican lawmakers prepare to leave Washington for a weeklong congressional recess, liberal groups and Democratic Party organizers are hoping to make their homecoming as noisy and uncomfortable as possible.
But national organizers concede they are playing catch-up to a ''dam-bursting level'' of grass-roots activism that has bubbled up from street protests and the small groups that have swelled into crowds outside local congressional offices.
Protests against the Republican agenda have become routine since President Trump took office, with momentum building through widely shared videos of lawmakers being confronted by constituents angry over efforts to repeal the Affordable Care Act. Now, national groups see the recess as the chance to capitalize on that local activism, with a show of might aimed at declaring the arrival of a new, and sustainable, political force -- barely three months after their humiliating defeat in November.
In email alerts, MoveOn.org is mobilizing members to attend town-hall-style meetings across the country, and it has set up a website, ResistanceRecess.com, to help people find them. The site includes a guide to ''health care recess messaging.'' (''The best and most impactful questions are ones where someone shares their story about what the Affordable Care Act has meant to them or their family,'' it instructs.)
Organizing for Action, the political nonprofit group that grew out of former President Barack Obama's election campaign, has created a ''Recess Toolkit'' with suggestions on how to effectively ask questions at the events. Last week, the group held an online seminar with members of Indivisible, the most prominent activist organization to emerge in response to Mr. Trump's election, to coach supporters on how to challenge lawmakers -- in a ''civil and respectful way'' advised one strategist, according to a recording of the session.
Planned Parenthood is hoping to flood the sessions with members in pink T-shirts, urging Congress to keep in place the health care law and the organization's funding.
''It's going to be intense,'' said Emily Tisch Sussman, who leads the political arm of the Center for American Progress, a liberal think tank in Washington. ''All every group wants to know is how to find out where the town halls are going to be.''
The recess, traditionally a time for lawmakers to take the temperature of their constituents, comes at a surprisingly vulnerable moment for Republicans. They are struggling to gain traction on a legislative agenda despite controlling both congressional chambers and the White House, as the new administration remains mired in controversy over its targeted travel ban and pre-election contact with Russia, among other issues.
While complaints about the health care act -- high premiums in particular -- helped elect Mr. Trump, polls show it has become more popular as voters realize that repealing it would mean that an estimated 30 million people lose health insurance.
There are few indications at this point that the conservative base of the Republican Party is mobilizing for action on a large scale during the recess. FreedomWorks, the Washington-based libertarian group that in 2009 nurtured Tea Party groups to rally against the legislation that became the health care act, said it was planning a Washington rally next month to let lawmakers know that there remained significant opposition to the Affordable Care Act.
But just as the energy after Mr. Obama's inauguration seemed to be on the right, this year it seems to be on the left. Anti-abortion demonstrations in some cities this month were met with much larger crowds of abortion rights supporters. At a widely viewed town-hall-style meeting held by Representative Gus Bilirakis in Florida, a local Republican Party chairman who declared that the health care act set up ''death panels'' was shouted down by supporters of the law.
Several Republicans, including Mr. Trump, have dismissed the pro-health care act crowds as ''paid protesters,'' not constituents. Sean Spicer, the White House press secretary, without offering evidence, called the protests a ''very paid, AstroTurf-type movement,'' unlike the Tea Party demonstrations against the drafting of the health care law in 2009, which he characterized as ''very organic.''
In fact, some of the most formidable and well-established organizing groups on the left have found themselves scrambling to track all of the local groups sprouting up through social media channels like Facebook and Slack, or in local ''huddles'' that grew out of the women's marches across the country the day after the inauguration.
''We're just constantly being flooded with people asking us, 'What can we do, where can we go?''' said Ben Wikler, the Washington director of MoveOn.org, who coined the ''dam-bursting level'' description. ''For politicians to imagine that it's something that any group could turn on and off like a light switch is a critical miscalculation.''
Ms. Sussman spent much of one morning this week communicating with 1,600 up-and-coming activist groups on a Slack channel that one of them organized.
''It doesn't work for organizations to bigfoot strategy; it's not the way organizing happens now,'' said Kelley Robinson, the deputy national organizing director for Planned Parenthood, which is fighting the defunding of its health clinics. ''There are bigger ideas coming out of the grass roots than the traditional organizations.''
Established groups in Washington are running more traditional campaigns.
The Alliance for Healthcare Security, a coalition of health care worker unions and other groups, is running television and online ads during the recess in five states where it believes Republican senators are either inclined to vote against a repeal of the Affordable Care Act, or vulnerable to defeat in re-election bids if they vote for repeal. The ads -- in Alaska, Arizona, Maine, Nevada and West Virginia -- feature constituents with life-threatening diseases telling emotional stories about how the health care law saved their lives.
The Democratic Congressional Campaign Committee is keeping track of Republican lawmakers who do not hold town-hall-style meetings. Some events have been canceled, and Representative Tom MacArthur of New Jersey said he had done so because the meetings have been ''hijacked'' by groups hostile to Mr. Trump. The committee plans to run internet ads trying to shame lawmakers for not facing their constituents in public since voting last month on a procedural motion aimed at repealing the health law.
Some of the most creative activity is coming from people who are new to political activism. In Plymouth, Minn., Kelly Guncheon, a financial planner who described himself as an independent, has organized a ''With Him or Without Him'' meeting for Representative Erik Paulsen, a Republican who has not scheduled any of his own. A volunteer offered to make 400 cupcakes decorated with a ''Where's Waldo?'' picture of Mr. Paulsen's face, and Mr. Guncheon said he planned to project onto screens legislation that Mr. Paulsen had supported. Participants will be asked to write down questions, which will be delivered, along with a recording of the event, to Mr. Paulsen's congressional office after the recess.
Mr. Guncheon, like other new activists, said he was not looking to traditional political groups for guidance.
''In this new culture, this new era, we have to figure out new ways to do things,'' he said. ''There's certainly no leadership at the head of the Democratic Party, or the state party. Not that I'm a Democrat anyway, but that seems to be the opposition party.''
Other new groups organizing on Facebook have arranged similar events, calling them ''no-show'' or ''empty-chair'' meetings, for Senators Cory Gardner of Colorado and Patrick J. Toomey of Pennsylvania, as well as for Republican lawmakers from California, New Jersey and New York.
In response to Mr. Gardner's complaints that the people showing up at his office to request town-hall-style meetings were paid protesters from other states, one group showed up at his office with a banner on which members had written their Colorado ZIP codes.
National groups are looking past the recess, to try to keep up the momentum for the local efforts.
Ms. Sussman, at the Center for American Progress, said her group planned a training and planning session in April for new activist leaders. Save My Care, another Washington group, is to begin an online campaign on Monday where people can register to have a hospital wristband sent to their congressional representative. The wristbands, which read ''I will lose my health care if you vote to repeal,'' will be delivered to Congress after the recess.
Planned Parenthood is signing up ''defenders'' and holding 90-minute training sessions to help teach new activists how to tell reporters and lawmakers their personal experiences with the group's health services, and what it would mean to lose them.
The group is planning a rally in Milwaukee on Feb. 25, the last weekend of the recess week, with Planned Parenthood patients from Speaker Paul D. Ryan's district expected to testify how they would be affected if clinics lost funding. Mr. Ryan has said he would defund Planned Parenthood in any repeal of the Affordable Care Act.
Still, said Nicole Safar, the group's director of government relations in Wisconsin, ''This is more about movement-building than targeting Paul Ryan.''
''This is a marathon, not a sprint,'' she said. ''We're going to put as much pressure as we can on Paul Ryan during the recess, for sure, but this isn't going to end any time soon.''
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URL: http://www.nytimes.com/2017/02/17/health/congress-recess-protest-planned-parenthood-obamacare.html
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GRAPHIC: PHOTOS: Above, a meeting held by Representative Jason Chaffetz, a Republican, last week in Cottonwood Heights, Utah. At left, people lined up in Elm Grove, Wis., to see Representative Jim Sensenbrenner. Several Republicans have said crowds at town-hall-style events are ''paid protesters.'' (PHOTOGRAPHS BY RICK BOWMER/ASSOCIATED PRESS
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July 1, 2012 Sunday
Late Edition - Final
Taking One for the Country
BYLINE: By THOMAS L. FRIEDMAN
SECTION: Section SR; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 11
LENGTH: 874 words
IN my mind, there are two lessons from the Supreme Court's 5-to-4 decision to support President Obama's health care plan: 1) how starved the country is for leadership that puts the nation's interest before partisan politics, which is exactly what Chief Justice John Roberts Jr. did; and 2) the virtue of audacity in politics and thinking big. Let's look at both.
It was not surprising to hear liberals extolling the legal creativity and courage of Chief Justice Roberts in finding a way to greenlight Obama's Affordable Care Act. But there is something deeper reflected in that praise, and it even touched some conservatives. It's the feeling that it has been so long since a national leader ''surprised'' us. It's the feeling that it has been so long since a national leader ripped up the polls and not only acted out of political character but did so truly for the good of the country -- as Chief Justice Roberts seemingly did.
I know that this was a complex legal decision. But I think it was inspired by a simple noble leadership impulse at a critical juncture in our history -- to preserve the legitimacy and integrity of the Supreme Court as being above politics. We can't always describe this kind of leadership, but we know it when we see it and so many Americans appreciate it.
This is still a moderate, center-left/center-right country, and all you have to do is get out of Washington to discover how many people hunger for leaders who will take a risk, put the country's interests before party and come together for rational compromises. Why do we all jump up and applaud at N.B.A. or N.F.L. games when they introduce wounded Iraq or Afghan war veterans in the stands? It's because the U.S. military embodies everything we find missing today in our hyperpartisan public life. The military has become, as the Harvard philosopher Michael Sandel once put it, ''the last repository of civic idealism and sacrifice for the sake of the common good.''
Indeed, I found myself applauding for Chief Justice Roberts the same way I did for Al Gore when he gracefully bowed to the will of the Supreme Court in the 2000 election and the same way I do for those wounded warriors -- and for the same reason: They each, in their own way, took one for the country.
To put it another way, Roberts undertook an act of statesmanship for the national good by being willing to anger his own ''constituency'' on a very big question. But he also did what judges should do: leave the big political questions to the politicians. The equivalent act of statesmanship on the part of our politicians now would be doing what Roberts deferred to them as their responsibility: decide the big, hard questions, with compromises, for the national good. Otherwise, we're doomed to a tug of war on the deck of the Titanic, no matter what health care plan we have.
I see no sign of Mitt Romney being ready for such a ''Roberts moment.'' I still have hope for Obama. He's entitled to a victory lap for daring to go big -- ignoring his advisers -- to bring health care to the whole country. It's a huge achievement.
But he needs to go just as big on the economy if he wants the Affordable Care Act to be something we can actually afford. That requires economic growth. Yet Obama's campaign has been all small-ball wedge issues, trying to satisfy enough micro-constituencies to get 50.1 percent of the vote.
Listen to the broad reaction to Roberts. Look at the powerful wave he has unleashed for big, centrist, statesmanlike leadership. That all tells me that people are also hungry for a big plan from the president to fix the economy, one that will bite and challenge both parties at the scale we need, fairly share the burdens and won't just be about ''balancing the budget,'' but about making America great again.
The opportunity for such a plan is hiding in plain sight. America today is poised for a great renewal.
Our newfound natural gas bounty can give us long-term access to cheap, cleaner energy and, combined with advances in robotics and software, is already bringing blue-collar manufacturing back to America. Web-enabled cellphones and tablets are creating vast new possibilities to bring high-quality, low-cost education to every community college and public school so people can afford to acquire the skills to learn 21st-century jobs. Cloud computing is giving anyone with a creative spark cheap, powerful tools to start a company with very little money. And dramatically low interest rates mean we can borrow to build new infrastructure -- and make money.
''We are at a transformational moment in terms of our potential as a country, and we have two candidates playing rope-a-dope,'' said David Rothkopf, author of ''Power, Inc.''
If we can just get a few big things right today -- a Simpson-Bowles-like grand bargain on spending and tax reform that unleashes entrepreneurship, a deal on immigration that allows the most energetic and smartest immigrants to enrich our country and a plan on energy that allows us to tap all these new sources in environmentally safe ways -- no one could touch us as a country. Connect the dots for people, Mr. President -- be the guy taking the risk to offer that big plan for American renewal, and Romney will never be able to touch you.
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February 4, 2011 Friday
Late Edition - Final
Virginia to Ask Supreme Court to Rule on Health Law
BYLINE: By KEVIN SACK
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 540 words
Virginia's attorney general announced on Thursday that he hoped to bypass an initial appellate review by asking the United States Supreme Court to consider the constitutionality of the Obama health care law on an expedited basis.
Only rarely does the Supreme Court grant such hearings, and it has already rejected a similar request in another legal challenge to the health care act. But the commonwealth's attorney general, Kenneth T. Cuccinelli II, said the legal and governmental confusion sown by conflicting lower-court opinions demanded a rapid resolution.
''Currently, state governments and private businesses are being forced to expend enormous amounts of resources to prepare to implement a law that in the end may be declared unconstitutional,'' Mr. Cuccinelli said in a statement.
In December, Mr. Cuccinelli became the first plaintiff to win a challenge to the health care act, when Judge Henry E. Hudson of Federal District Court in Richmond, Va., struck down a provision that requires most Americans to obtain insurance. The judge ruled that the insurance requirement exceeded Congress's authority under the Constitution to regulate interstate commerce.
Two other federal judges, including another in Virginia, had previously upheld the law. Then on Monday, Judge Roger Vinson of Federal District Court in Pensacola, Fla., joined Judge Hudson in striking down the insurance mandate. But unlike Judge Hudson, Judge Vinson invalidated the entire law.
The law, enacted last year by a Democratic Congress and signed in March by President Obama, aims to cover 32 million uninsured Americans by ending insurer discrimination against those with pre-existing health conditions and by providing government subsidies to make coverage affordable.
The Justice Department, which is defending the Obama administration in the health litigation, has already filed a notice of appeal of Judge Hudson's ruling in the Court of Appeals for the Fourth Circuit in Richmond. Because of the geographic distribution of the four lower court rulings, three different courts of appeal are likely to hear the cases on their way to the Supreme Court.
Tracy Schmaler, a spokeswoman for the Justice Department, said the agency continued ''to believe this case should follow the ordinary course'' so that legal arguments could be fully developed before being presented to the Supreme Court. She pointed out that the insurance mandate does not take effect until 2014 and that the Fourth Circuit has already expedited its schedule by setting oral arguments for May.
The Justice Department also is considering whether to seek a stay of the Florida decision in order to clarify confusion about whether the health care act remains in effect in the 26 states that are plaintiffs in the case.
Mr. Cuccinelli said he recognized that an expedited Supreme Court review would be exceptional. But he said that this case and the others challenging the constitutionality of the Patient Protection and Affordable Care Act, as the law is known, were ''truly exceptional in their own right.''
In November, the Supreme Court refused to review another challenge to the health care act that had been dismissed by a California judge on grounds that the plaintiffs did not have standing to sue.
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The New York Times
October 27, 2014 Monday
Late Edition - Final
Health Law Delivers on Promises, With Notable Failings, in First Year
BYLINE: By MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 339 words
''Relish this moment,'' President Obama told his weary staff during a Champagne toast at an early-morning White House celebration in March 2010. Moments before, he had stood in the East Room to hail passage of the Affordable Care Act, ''Obamacare'' to its detractors.
''Long after the debate fades away,'' Mr. Obama said, what will remain is a health care system ''that works better for the American people.''
The debate has hardly faded. But it is possible to begin assessing whether Mr. Obama was right about his biggest domestic policy accomplishment. A year after it took full effect, the law has largely succeeded in delivering on his main promises, even as it has fallen short in some ways and given birth to a new and powerful conservative movement.
An examination of the law's key areas reveals the successes: Millions more people have insurance and many are finding the coverage affordable, thanks to government subsidies, new competition among private insurers and a vastly expanded Medicaid program.
The health care industry also seems to have benefited financially from the law, while fewer people are in danger of drowning in health care debt. There is evidence that more people are seeing doctors, and even HealthCare.gov, the online insurance marketplace that failed disastrously last fall, is widely expected to work more smoothly when it goes back online next month.
But measuring the law's long-term impact is not yet possible. Millions more people have insurance today, but the total number of uninsured will remain about 30 million for years to come. Though more individuals are seeing doctors, it remains unclear whether the nation as a whole is getting healthier.
Politically, the law has also not served Mr. Obama or his party well, fueling the anger that helped spawn the Tea Party movement. And while demands for repeal have faded, the law still stands as a symbol of everything that conservatives consider wrong with government. And Democrats are bracing for the possibility of losing control of Congress next month.
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September 18, 2014 Thursday
Late Edition - Final
F.T.C. Wary of Mergers by Hospitals
BYLINE: By ROBERT PEAR
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1
LENGTH: 1268 words
WASHINGTON -- As hospitals merge and buy up physician practices, creating new behemoths, one federal agency is raising a lonely but powerful voice, suggesting that consumers may be victimized by the trend toward consolidation.
Hospitals often say they acquire other hospitals and physician groups so they can coordinate care, in keeping with the goals of the Affordable Care Act. But the agency, the Federal Trade Commission, says that mergers tend to reduce competition, and that doctors and hospitals can usually achieve the benefits of coordinated care without a full merger.
The commission is using a 100-year-old law, the Clayton Antitrust Act of 1914, to challenge some of the mergers and acquisitions, and it has had remarkable success in recent cases.
''Hospitals that face less competition charge substantially higher prices,'' said Martin S. Gaynor, director of the F.T.C.'s bureau of economics, adding that the price increases could be ''as high as 40 percent to 50 percent.''
Leemore S. Dafny, a professor and health economist at Northwestern University who used to work at the commission, said, ''The Affordable Care Act has unleashed a merger frenzy,'' and she said she saw antitrust enforcement as a powerful tool to slow ''the march toward conglomeration.''
When the American Health Lawyers Association and the American Bar Association held a conference here in May, scores of lawyers sought guidance from the commission. The conference agenda explained why: ''The agency is riding high with wins in three litigated hospital mergers in the last two years'' -- in Albany, Ga.; Toledo, Ohio; and Rockford, Ill. -- and ''the F.T.C. just won its first-ever litigated case challenging a health system acquisition of a physician group,'' in Idaho.
''The F.T.C. is on a winning streak,'' said Melinda R. Hatton, senior vice president and general counsel of the American Hospital Association, and its victories have had ''a chilling effect'' on hospital mergers.
Doctors and hospitals say they must collaborate to survive and thrive under the Affordable Care Act.
But Deborah L. Feinstein, director of the bureau of competition at the Federal Trade Commission, said the health care law did not repeal the antitrust laws.
''I don't think there's a contradiction between the goals of health care reform and the goals of antitrust,'' Ms. Feinstein said in an interview, as she surveyed the wave of mergers, consolidations and affiliations sweeping through the health care industry.
Edith Ramirez, the chairwoman of the commission, said it had challenged fewer than 1 percent of hospital deals. But the message of those cases is reverberating in the health care industry.
In the Idaho case, Federal District Judge B. Lynn Winmill acknowledged that the combination in 2012 of St. Luke's Health System and the Saltzer Medical Group -- the largest independent physician group in the state -- was primarily intended to improve care for patients. But, he said, ''there are other ways to achieve the same effect that do not run afoul of the antitrust laws.''
Judge Winmill said the combined entity would have a huge share of the market for primary care physician services and could charge higher prices to health insurance plans, which could then pass the costs to consumers by charging higher premiums.
''The Clayton Act is in full force, and it must be enforced,'' the judge said, noting that the law bans mergers that may substantially lessen competition. He ordered the hospital system to divest itself of the physician group. The decision is being appealed.
A federal investigation can be an ordeal for hospital executives. ''I was shocked at how aggressive the F.T.C. was,'' said Randy Oostra, the president of ProMedica, the hospital system at the center of the Ohio case.
Jeffrey C. Kuhn, the general counsel of ProMedica, said: ''The government has lots of resources and lots of lawyers. Their attitude was adversarial. Our trustees and top executives had to fly to Washington to be deposed. We were eager to tell our story, but it quickly turned into an inquisition. We turned over millions of pages of documents, at great expense.''
A federal appeals court said in April that the commission was justified in blocking the merger of ProMedica with a smaller hospital in the Toledo area.
''The commission's analysis of this merger was comprehensive, carefully reasoned and supported by substantial evidence,'' the appeals court said, and it found that the deal would hurt the community by forcing higher rates on consumers.
Hospitals often contend that the antitrust laws are at odds with the goals of the Affordable Care Act because they limit the ability of doctors and hospitals to join forces and collaborate.
Federal officials see no conflict. The health care law and the antitrust laws, they say, have the same goals: to lower costs, increase access to care and improve its quality by fostering competition.
''You can have collaboration, you can have consolidation, you can have cooperation, and we don't worry if it doesn't harm competition,'' said Mr. Gaynor, the chief economist at the commission.
In Illinois, the commission challenged a merger that it said would ''eliminate vigorous competition'' among hospitals and primary care doctors in the Rockford area.
''The F.T.C. has shown that the merger would likely lead to higher prices,'' said the judge, Frederick J. Kapala of the Federal District Court in Rockford. He granted a preliminary injunction, and the hospitals promptly abandoned their plans to merge.
Hospital executives say mergers can benefit consumers by pumping money into struggling institutions in order to buy new medical equipment and adopt electronic health records. In other cases, hospitals say their goal is to increase the quality of care, lower its cost and eliminate duplication -- for example, by consolidating cardiac care or cancer treatment at one site.
Federal officials view such arguments with skepticism and require hospitals to document the benefits with detailed studies.
''Vague promises and aspirations that an acquisition will reduce costs and improve care are not sufficient,'' said Julie Brill, a member of the commission.
Often, Ms. Feinstein said, when hospitals and doctors join forces, their goal is not just to control costs or improve care, but to ''get increased leverage'' in negotiations with health insurance companies and employers.
''They say they need better rates so they will have more money to invest in their facilities,'' Ms. Feinstein said. ''When you strip that down, it's basically just saying, 'We want a price increase.' Even if the price increase is motivated by a desire to invest more in the business, that's problematic. That incentive to invest may not be there if you don't have competition as a spur to innovation -- if you're not worried about losing business to the hospital down the street.''
The F.T.C. has long argued that mergers can cause higher prices by reducing competition among hospitals in the same market. New research suggests that another dynamic, rarely considered by antitrust officials, can also lead to significant price increases.
The research shows that hospitals gain bargaining power when they are acquired and become part of a big hospital system that has no other presence in the local market.
''Acquisitions of hospitals by large national chains such as Hospital Corporation of America, Ascension Health or Tenet Healthcare may not increase hospital concentration in the affected local markets, but could nevertheless generate higher prices,'' said Matthew S. Lewis, an associate professor of economics at Clemson University.
URL: http://www.nytimes.com/2014/09/18/business/ftc-wary-of-mergers-by-hospitals-.html
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June 29, 2012 Friday
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'It Is Not Our Role to Forbid It, or to Pass Upon Its Wisdom'
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From the Majority Opinion
Excerpts from the opinions in the decision handed down Thursday by the Supreme Court in the case involving the Patient Protection and Affordable Care Act of 2010:
''The Affordable Care Act's requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax. Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.''
On whether failure to buy insurance imposes a penalty or a tax
''While the individual mandate clearly aims to induce the purchase of health insurance, it need not be read to declare that failing to do so is unlawful. Neither the act nor any other law attaches negative legal consequences to not buying health insurance, beyond requiring a payment to the I.R.S.
''Indeed, it is estimated that four million people each year will choose to pay the I.R.S. rather than buy insurance. We would expect Congress to be troubled by that prospect if such conduct were unlawful. That Congress apparently regards such extensive failure to comply with the mandate as tolerable suggests that Congress did not think it was creating four million outlaws. It suggests instead that the shared responsibility payment merely imposes a tax citizens may lawfully choose to pay in lieu of buying health insurance.''
''The required payment is not called a 'tax,' a 'penalty,' or anything else. No one would doubt that this law imposed a tax, and was within Congress's power to tax. That conclusion should not change simply because Congress used the word 'penalty' to describe the payment.''
''Whether the mandate can be upheld under the commerce clause is a question about the scope of federal authority. Its answer depends on whether Congress can exercise what all acknowledge to be the novel course of directing individuals to purchase insurance. Congress's use of the taxing clause to encourage buying something is, by contrast, not new. Tax incentives already promote, for example, purchasing homes and professional educations. Sustaining the mandate as a tax depends only on whether Congress has properly exercised its taxing power to encourage purchasing health insurance, not whether it can. Upholding the individual mandate under the taxing clause thus does not recognize any new federal power. It determines that Congress has used an existing one.''
Chief Justice Roberts for himself on the role of the court:
''Members of this court are vested with the authority to interpret the law; we possess neither the expertise nor the prerogative to make policy judgments. Those decisions are entrusted to our nation's elected leaders, who can be thrown out of office if the people disagree with them. It is not our job to protect the people from the consequences of their political choices. Our deference in matters of policy cannot, however, become abdication in matters of law.''
Chief Justice Roberts for himself on rejecting the individual mandate under the commerce clause:
''Allowing Congress to justify federal regulation by pointing to the effect of inaction on commerce would bring countless decisions an individual could potentially make within the scope of federal regulation, and -- under the government's theory -- empower Congress to make those decisions for him.''
''Everyone will likely participate in the markets for food, clothing, transportation, shelter, or energy; that does not authorize Congress to direct them to purchase particular products in those or other markets today. The commerce clause is not a general license to regulate an individual from cradle to grave, simply because he will predictably engage in particular transactions. Any police power to regulate individuals as such, as opposed to their activities, remains vested in the States.''
Chief Justice Roberts for himself on dismissing the relevance of the Anti-Injunction Act:
''The Affordable Care Act does not require that the penalty for failing to comply with the individual mandate be treated as a tax for purposes of the Anti-Injunction Act. The Anti-Injunction Act therefore does not apply to this suit.''
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November 1, 2016 Tuesday
Late Edition - Final
Visualizing Obamacare
BYLINE: By MARGOT SANGER-KATZ and QUOCTRUNG BUI
SECTION: Section A; Column 0; National Desk; Pg. 3
LENGTH: 1008 words
This article was published online this morning in interactive form
The share of people without health insurance keeps falling.
Since 2013, when the major provisions of Obamacare went into effect, the uninsured rate has fallen in every state. And some states that you might not expect have led the way.
The news about the Affordable Care Act has been grim lately: The price of health plans in new marketplaces is up, and choice is declining in many places. But amid the difficulties, new data highlight the law's effectiveness in getting coverage for millions of Americans.
Over all, the gains are substantial: a seven-percentage-point drop in the uninsured rate for adults. But there remain troublesome regional patterns. Many people in the South and the Southwest still don't have a reliable way to pay for health care, according to the new, detailed numbers from a pair of groups closely tracking enrollment efforts. Those patterns aren't an accident. As our maps show, many of the places with high uninsured rates had poor coverage before the Affordable Care Act passed. They tend to be states with widespread poverty and limited social safety nets. Look at Mississippi and Texas, for example.
But many of the places that have reduced their uninsured rates the most had similar characteristics in 2013. Look at Kentucky and Arkansas. Over the years, you can see them diverge sharply from their neighbors.
The differences reflect a number of factors, but there is one big one: a state's decision about whether to expand its Medicaid program. States that expanded saw much larger declines in their uninsured rates compared with those that didn't. It appears that Medicaid expansion has had a couple of effects: It provided a new coverage option for childless adults below or near the poverty line. It helped spur many people who were already eligible for the program to sign up. And it may have helped boost enrollment in Obamacare's marketplace plans. Take a look at Montana, which expanded its Medicaid program this year -- it experienced immediate, sharp reductions in the number of residents without insurance. (Louisiana also expanded its program this year, but the expansion began after the research used to make the map was conducted.)
The numbers used to make our maps come from two organizations that are closely tracking the progress of the health law. For the last two years, Enroll America and Civis Analytics have shared with The Upshot the results of their research into where the uninsured live. They use the data to help identify people who may be eligible for coverage and need help signing up.
The new marketplaces have struggled to attract a large share of young, healthy customers, which is part of why costs there have been higher than insurers expected. But the Enroll America data suggest that, over all, a lot of young people who had no insurance before have it now. Researchers measured a five-percentage-point drop in the uninsured rate among adults under 35 in 2016 alone.
The Enroll analysis found that states that expanded Medicaid in 2014 showed big reductions, but states that expanded the next year caught up quickly. Those data suggest that states yet to expand could expect results similar to neighbors that made the policy change earlier. (For a glimpse of what the country might have looked like in 2014 if every state had expanded Medicaid, look at the map here.)
''The states that expanded early, they obviously saw an immediate decline,'' said Ed Coleman, the national analytics and data director at Enroll America. ''But the states that expanded late, they caught up almost right away. They get very immediate and dramatic benefits.''
Medicaid expansion is not the only way states have increased the number of residents with health insurance. One of the most striking trends in the three-year Enroll data is that many of the states with the largest reductions in the uninsured in 2014 also had the largest ones this year.
West Virginia started near the bottom of the pack in 2013. It had high rates for the uninsured and poverty, and ranked low on measures of public health. But state officials, health care providers and local advocacy groups embraced the Affordable Care Act wholeheartedly -- and avoided the word Obamacare. The state didn't just expand Medicaid, but also took extra efforts to identify residents who were likely to be eligible for new insurance, sought them out, and made it easier for them to sign up. Even after the Medicaid expansion sharply reduced the state's uninsured rate in 2014, advocates like Terri Giles, the executive director of West Virginians for Affordable Health Care, continued to press for more people to sign up for health coverage.
West Virginia is a red state, and opposition to the president's health law can run strong. But Ms. Giles said that she had faced little pushback as she's spoken to county officials around the state, encouraging them to help with sign-up efforts. ''At first, we might have had some hesitancy,'' she said. ''But the proof is in the pudding, and the pudding is delicious in West Virginia.''
There's a governor's race this year in the state, but both candidates say they are committed to preserving the Medicaid expansion and other sign-up programs.
Arkansas, another big success story, used some of the same automatic enrollment strategies. Kentucky gave residents a single, simple website to sign up for Medicaid or buy health insurance, though the new governor just shut down the site. California, a blue state, started early with Medicaid, and has focused on its insurance marketplace for middle-class residents, and has invested heavily in outreach to uninsured populations. Parts of the state still have a lot of uninsured residents, but the number has fallen every year.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
This is a more complete version of the story than the one that appeared in print.
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November 18, 2013 Monday
Late Edition - Final
Washington Insurance Official Is Ousted
BYLINE: By SUSANNE CRAIG and MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 558 words
The insurance commissioner for the District of Columbia was dismissed from his job just a day after he publicly questioned a decision by President Obama to reverse a provision of the Affordable Care Act, a person with knowledge of the events said on Sunday.
This person said that the commissioner, William P. White, had requested but never received permission from the office of Mayor Vincent C. Gray to publish a critique of Mr. Obama's surprise announcement on Thursday that he would allow thousands of Americans to renew policies that might not provide the minimum coverage required by the health law.
Instead of waiting to hear from Mr. Gray's office, the person said, Mr. White's office posted the statement on the city government's website less than 15 minutes after sending an email seeking approval. Later, when confronted by the mayor, Mr. White said he had received permission from the mayor's staff even though he had not, the person said.
In an interview, Mr. White said that Victor L. Hoskins, Washington's deputy mayor, told him that the mayor had ''decided to go in a different direction'' and that Mr. White's services would no longer be needed. Mr. White, who had been commissioner for roughly three years, said his statement on the Affordable Care Act was not mentioned during his conversation with Mr. Hoskins.
Mr. White said that although he commonly sent releases to the mayor's office, it was not his normal practice to wait for the mayor or the mayor's office to sign off. He added that he did not misrepresent to the mayor that he had permission to send out the release.
''When I issue statements, I am speaking on behalf of the department about insurance, and I don't speak on behalf of the mayor,'' Mr. White said. ''In this instance, however, the issue was clearly more political than usual.''
Michael M. Flagg, a spokesman for Mr. White, referred questions to the mayor's office, saying he could not discuss personnel matters.
Mr. White's statement took direct issue with Mr. Obama's decision, saying the president's policy reversal to allow the continuation of canceled policies ''undercuts the purpose of the exchanges, including the District's DC Health Link, by creating exceptions that make it more difficult for them to operate.''
Mr. Obama had been criticized heavily over the canceled policies because he had said many times that people who liked their insurance would be able to keep it under the new law. Mr. Obama's reversal, which allows states to continue policies that had been canceled but does not require that they do so, threw the issue into the laps of insurance companies and insurance commissioners like Mr. White, who typically regulate insurance policies.
In a meeting with Mr. Obama at the White House on Friday, executives for the major insurance companies expressed mixed feelings about whether the continuation of canceled policies could work in every state.
At the same time, several insurance commissioners voiced their opinions on the move.
''I do not believe his proposal is a good deal for the State of Washington,'' Mike Kreidler, the insurance commissioner there, said Thursday.
The commissioner in Florida, by contrast, supported the proposal.
The person with knowledge of the situation said that Mayor Gray was unhappy with the tone of Mr. White's statement, if not the substance of its arguments.
URL: http://www.nytimes.com/2013/11/18/us/politics/dc-mayor-dismisses-insurance-commissioner-who-criticized-obama.html
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September 24, 2014 Wednesday
Late Edition - Final
A Health Care Success Story
BYLINE: By BOB KOCHER and FARZAD MOSTASHARI.
Bob Kocher was special assistant to , President Obama for health care and economic policy from 2009 to 2010. Farzad Mostashari was national coordinator for health information technology at the Department of Health and Human Services from 2011 to 2013.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTORS; Pg. 31
LENGTH: 727 words
IT may have been the most influential magazine article of the past decade. In June of 2009, the doctor and writer Atul Gawande published a piece in The New Yorker called ''The Cost Conundrum,'' which examined why the small border city of McAllen, Tex., was the most expensive place for health care in the United States.
The article became mandatory reading in the White House. President Obama convened an Oval Office meeting to discuss its key finding that the high cost of health care in the country was directly tied to a system that rewarded the overuse of care. The president also brought up the article at a meeting with Democratic senators, emphasizing that McAllen represented the problem that needed to be fixed.
Five years later, the situation has changed. Where McAllen once illustrated the problem of American health care, the city is now showing us how the problem can be solved, largely because of the Affordable Care Act that Mr. Obama signed into law in 2010.
In his article, Dr. Gawande cited studies showing that patients in high-cost areas like the Rio Grande Valley, which includes McAllen, were much less likely to receive preventive services like cancer screenings or vaccines, but far more likely to be prescribed costly drugs, invasive procedures and expensive diagnostic tests. And they were not any healthier for it: Compared with places like El Paso, McAllen had worse health outcomes, despite spending twice as much per capita on Medicare.
The problem was that doctors in McAllen were responding to reimbursement incentives in the American health care system that rewarded activity rather than value. The more procedures and visits a doctor billed, the more he got paid.
The Affordable Care Act was designed to change that. One of its provisions created the Medicare Shared Savings Program, which rewards doctors for keeping their patients healthy. Participation in the program requires primary care doctors to create networks, called accountable care organizations, or A.C.O.s, to better coordinate patient care. These networks are reimbursed for delivering high-quality care below a baseline of historical Medicare costs.
In 2012, doctors in McAllen formed the Rio Grande Valley Accountable Care Organization Health Providers, and signed up for this experiment. The early results are in, and they are stunning: From April 2012 to the end of 2013, the Rio Grande Valley A.C.O. saved more than $20 million from its Medicare baseline.
(One of us, Farzad Mostashari, is the C.E.O. of Aledade, which works with primary care physicians to help them form A.C.O.s; the other, Bob Kocher, is a partner in the venture capital firm Venrock, an investor in Aledade. We are not involved in the Rio Grande Valley A.C.O.)
From the beginning, physicians in the Rio Grande Valley A.C.O. analyzed data from their electronic health records to identify -- and then focus on -- high-risk patients. Patients who couldn't get to the office were visited at home; those who had trouble communicating with their doctors were given cellphones.
Preventive care became a central focus. Doctors advised patients about diet and lifestyle changes that could prevent future health problems, and developed personal care plans for patients with uncontrolled diabetes. Patients who had recently had a hospital stay were scheduled for rapid follow-up visits to make sure that their recoveries were on track.
These changes didn't just save money; they also improved patients' health. From 2012 to 2013, the number of patients achieving control of their diabetes rose 11.8 percentage points. The number receiving vaccinations rose 12.2 percentage points.
This is not an isolated case. Today, more than 5.3 million Medicare beneficiaries nationwide are served by more than 360 A.C.O.s, which have helped hold spending hundreds of millions of dollars below Medicare targets for this period. Many primary care physicians -- who are responsible for directing the vast majority of health care costs -- are forming A.C.O.s, and more private health plans are setting up these reimbursement structures as well.
A continued slowing of health care cost growth will owe a good deal to this revolution in how we pay for medical care. It is a transformation that was sparked by the Affordable Care Act, and is now being played out throughout the country -- even in the little Texas city of McAllen.
URL: http://www.nytimes.com/2014/09/24/opinion/a-health-care-success-story.html
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October 30, 2013 Wednesday
The Uproar Over Insurance 'Cancellation' Letters
BYLINE: DAVID FIRESTONE
SECTION: OPINION
LENGTH: 472 words
HIGHLIGHT: The so-called cancellation letters waved around at today’s hearing were simply notices that policies would have to be upgraded or changed.
Kathleen Sebelius, the Health and Human Services secretary, took a lot of grief this morning from Republicans on the House Energy and Commerce Committee who were outraged that some people's individual insurance policies had been "cancelled" because of health care reform.
Some of the rants bordered on the comical. Cory Gardner, Republican of Colorado, brandished his "cancellation" letter and demanded that Ms. Sebelius nullify the health law for all residents of his congressional district.
Most lawmakers mentioned President Obama's unfortunate blanket statement that all Americans would be allowed to keep their insurance policies if they liked them. He failed to make an exception for inadequate policies that don't meet the new minimum standards.
But in between lashings, Ms. Sebelius managed to make an important point. Yes, some people will be forced to upgrade their policies, she said. But that's preferable to the status quo before the passage of the Affordable Care Act, when insurers could cancel policies on a whim.
"The individual market in Kansas and anywhere in the country has never had consumer protections," she testified at the hearing. "People are on their own. They could be locked out, priced out, dumped out. And that happened each and every day. So this will finally provide the kind of protections that we all enjoy in our health care plans."
A true cancellation is when someone gets a letter saying that she's losing her insurance and cannot renew. That was common practice in the individual market for people with expensive conditions. Under the new law, no one will ever get a letter like that again. They cannot be turned down for insurance.
The so-called cancellation letters waved around at yesterday's hearing were simply notices that policies would have to be upgraded or changed. Some of those old policies were so full of holes that they didn't include hospitalization, or maternity care, or coverage of other serious conditions.
Republicans were apparently furious that government would dare intrude on an insurance company's freedom to offer a terrible product to desperate people.
"Some people like to drive a Ford, not a Ferrari," said Marsha Blackburn of Tennessee. "And some people like to drink out of a red Solo cup, not a crystal stem. You're taking away their choice."
Luckily, a comprehensive and affordable insurance policy is no longer a Ferrari; it is now a basic right. In the face of absurd comments and analogies like this one, Ms. Sebelius never lost her cool in three-and-a-half hours of testimony, perhaps because she knows that once the computer problems and the bellowing die down, the country will be far better off.
Creepy Uncle Sam Is Back, With More Bad Advice
G.O.P. Roots for Failure
Some Republicans Change Course on Health Care
Is the Health Care Fight Over?
Boehner's Last Stand
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December 22, 2016 Thursday
Late Edition - Final
Sign-Ups Jump as Health Law Faces a Repeal
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1135 words
WASHINGTON -- About 6.4 million people have signed up for health insurance next year under the Affordable Care Act, the Obama administration said Wednesday, as people rushed to purchase plans regardless of Republican promises that the law will be repealed within months.
The new sign-ups -- an increase of 400,000 over a similar point last year -- mean the health care coverage of millions of consumers could be imperiled by one of the first legislative actions of Donald J. Trump's presidency. Hundreds of thousands of other people who took no action will be automatically re-enrolled by the federal government in the same or similar plans, officials said, and their coverage could be threatened as well. Consumers still have until the end of January to enroll.
Sylvia Mathews Burwell, the secretary of health and human services, said the number of sign-ups was remarkable in view of ''headwinds'' created by premium increases for 2017 and by the uncertainty of the entire health law after Mr. Trump takes office on Jan. 20.
Americans remain divided over President Obama's most significant legislative achievement, even as 20 million people have gained coverage under the law and the percentage of those without insurance has dropped to record lows. Mr. Trump and Republican leaders of the House and the Senate have vowed to repeal the 2010 law as one of the first legislative actions of the Trump era.
To lay the political groundwork, Republicans have portrayed the law as collapsing under its own weight, unable to hold down health costs or provide the insurance choices its advocates promised.
But the 6.4 million signing up on HealthCare.gov through Monday could undermine the argument that the law is in free fall. The five states with the most people enrolling for coverage on the site through Monday were Florida, with 1.3 million plan selections, Texas (776,000), North Carolina (369,000), Georgia (352,000) and Pennsylvania (291,000). Mr. Trump carried all those states.
And the 6.4 million figure does not include data from states like New York and California that use their own digital marketplaces.
Democrats say that repealing the law will cause chaos and catastrophe, jeopardizing coverage for people who use HealthCare.gov and millions more who have been able to enroll in Medicaid. Whether those consumers like their coverage enough to fight for it and to resist Republican efforts to undo the law is unclear. But the enrollment figures will provide a rallying cry for Democrats intent on saving it.
''Enrollment is running ahead of last year,'' Ms. Burwell said. ''Today's enrollment numbers confirm that doomsday predictions about the marketplace are wrong.''
For their part, Republicans reiterated their concerns.
''This disaster of a law has led to massive premium spikes, less choice for patients and a collapse of the exchange markets, and no amount of spinning from the White House can hide this ugly reality,'' AshLee Strong, a spokeswoman for Speaker Paul D. Ryan of Wisconsin, said Wednesday.
The Trump team tried to allay concerns by promising a smooth transition to a new version of health care coverage, echoing congressional Republicans, who have floated the idea of quickly repealing the law and then delaying the effective date for several years as they try to agree on a different approach to the nation's health care problems.
''The enrollment numbers announced today show just how important health care coverage is to millions of Americans,'' said Phillip J. Blando, a spokesman for the Trump transition team. ''The Trump administration will work closely with Congress, governors, patients, doctors and other stakeholders to fix the Affordable Care Act's well-documented flaws and provide consumers with stable and predictable health plan choices.''
A number of Republican governors, including Vice President-elect Mike Pence of Indiana, supported the expansion of Medicaid eligibility under the Affordable Care Act, and some have expressed reservations about Republican plans to repeal that part of the law.
Some Republican senators have expressed similar reservations.
Thomas P. Miller, a health economist at the American Enterprise Institute and a harsh critic of the health law, predicted that the new numbers would have ''a negligible effect'' on the Trump administration and Republicans in Congress. ''The Obama administration gets an A for effort in marketing puffery,'' he said, ''but remains stuck with a C for execution.''
Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee, was similarly unimpressed. ''Initial enrollment numbers for the health law have long been flawed, as they do not account for consumers who actually follow through and pay the premiums,'' he said. ''A closer look will be needed down the road to determine the final, real enrollment numbers.''
But consumers are becoming concerned, administration officials say. Ms. Burwell said the federal call center had ''heard from more than 30,000 people worrying about the future of their coverage in the wake of the election, and wondering whether they should still sign up for a 2017 plan.''
The answer, she said, is a definite yes.
Some people might have been rushing to sign up because they were concerned about losing coverage they had gained under the health law, acknowledged Andrew M. Slavitt, the acting administrator of the Centers for Medicare and Medicaid Services. A larger factor, he said, is that people need coverage and are finding it affordable.
Most consumers shopping in the public marketplace can find coverage for less than $75 a month after receiving subsidies, the administration said. But to find such bargains, consumers may have to switch plans and change doctors, officials said.
Last Thursday alone, Ms. Burwell said, 670,000 people enrolled, setting a record.
Monday was the deadline for people to sign up for coverage starting Jan. 1. The open enrollment period, which began on Nov. 1, ends on Jan. 31, 11 days after Mr. Trump takes office.
The Obama administration predicted in October that 13.8 million people would sign up for coverage or be automatically re-enrolled through the federal and state marketplaces by the end of January, and Ms. Burwell said Wednesday that she stood by that prediction.
In the past week, Obama administration officials have tried to lock in place their health policies by issuing a batch of final rules before Mr. Trump takes office.
One rule, the annual ''notice of benefit and payment parameters,'' includes detailed standards for plan benefits, eligibility and enrollment under the Affordable Care Act. Most of the new standards apply to insurance sold in 2018. Some apply to 2019, a sign that the administration hopes the law will still be in place well into the Trump administration.
URL: http://www.nytimes.com/2016/12/21/us/health-exchange-enrollment-jumps-even-as-gop-pledges-repeal.html
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October 2, 2015 Friday
Late Edition - Final
Health Law Revision Is Approved
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 504 words
WASHINGTON -- The Senate passed legislation on Thursday intended to protect small and midsize businesses from increases in health insurance premiums, clearing the bill for President Obama's expected signature.
The action by Congress was a rare example of bipartisan agreement on how to revise the Affordable Care Act.
The bill, approved this week in the House and the Senate by voice vote, eliminates a provision of the law that would have imposed tough, potentially costly new requirements on businesses with 51 to 100 employees.
A White House spokeswoman confirmed that Mr. Obama would sign the bill, but she declined to discuss its substance. Recent comments by administration officials suggested that they did not particularly like the legislation but could not stop the growing wave of bipartisan support for it.
At issue is a provision of the health care law that expands the definition of a ''small employer'' to include companies with 51 to 100 employees, subjecting them to stringent insurance regulation starting Jan. 1. States have historically defined small employers as those with 50 or fewer employees.
The bill preserves the traditional definition of ''small group,'' but allows states to expand it to include organizations with 51 to 100 employees if they want to do so.
Senator Tim Scott, Republican of South Carolina, the chief sponsor of the Senate version of the bill, said it would ensure that ''small-business owners all across America are not more negatively impacted by Obamacare.''
Senator Jeanne Shaheen of New Hampshire, the senior Democrat on the Small Business and Entrepreneurship Committee, said that passage of the bill was ''a win for businesses across this country, a win for bipartisanship.''
''This bill will make a helpful adjustment to the Affordable Care Act for small and midsize businesses by limiting potential premium increases and letting states determine what's best for their market,'' Mrs. Shaheen said.
The House passed the measure Monday. Representative Brett Guthrie, Republican of Kentucky, the chief sponsor, said he had heard from many small-business owners who feared that their insurance arrangements would be disrupted by ''the mandated expansion of the small-group market.''
Kurt Giesa, an actuary at Oliver Wyman, a management consulting concern, told Congress at a hearing last month that employers with 51 to 100 employees would face premium increases averaging 18 percent next year if they were subjected to the new requirements.
''Many of the groups receiving such sizable increases would elect to drop their health insurance coverage and either self-fund or not offer any coverage at all,'' Mr. Giesa testified.
The swift passage of the legislation followed months of lobbying and advocacy. Among those who endorsed the bill were the National Association of Insurance Commissioners, the United States Chamber of Commerce, the National Federation of Independent Business, America's Health Insurance Plans and the Blue Cross and Blue Shield Association.
URL: http://www.nytimes.com/2015/10/02/us/health-law-revision-is-approved.html
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The New York Times
October 9, 2016 Sunday
Late Edition - Final
HealthCare.gov Offers Warning for Undecided Consumers: We'll Pick for You
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 22
LENGTH: 1124 words
WASHINGTON -- The federal government will choose health plans for hundreds of thousands of consumers whose insurers have left the Affordable Care Act marketplace unless those people opt out of the law's exchanges or select plans on their own, under a new policy to make sure consumers maintain coverage in 2017.
''Urgent: Your health coverage is at risk,'' declares a sample ''discontinuation notice,'' drafted by the government for use by insurers. It tells consumers that ''if you don't enroll in a plan on your own, you may be automatically enrolled in the plan picked for you.''
That may make for a jarring start to the health law's fourth annual open enrollment period, which starts Nov. 1, a week before Election Day, and runs through Jan. 31. While the administration says 20 million people have gained insurance through President Obama's signature health law, it has suffered setbacks: Nonprofit health insurance co-ops created by the law have shut down; major health insurers have withdrawn from its marketplaces; and the ones that remain have raised premiums sharply.
Now, as the administration struggles to adjust to those changes, consumers may be surprised to learn that they have been placed in a health plan offered by a different insurance company, which is likely to have different doctors, benefits and drugs that are covered.
Consumers in discontinued plans will often receive a welcome kit from the new company, with a bill for the January 2017 premium.
''Without health coverage or an exemption,'' the discontinuation notice says, ''you may have to pay a penalty of $695 or more when you file your taxes.''
Assigning consumers to alternate plans, the Obama administration says, will protect them from coverage lapses. And, it notes, consumers are free to choose another plan if they do not like the one chosen for them. But the alternatives may be limited. In Maricopa County, Ariz., which includes Phoenix, the number of insurers in the public marketplace may drop to one, from eight this year.
Brett Barry, 51, of Phoenix, had coverage last year from a nonprofit co-op, Meritus, but it closed, forcing 59,000 Arizona residents to shop for another plan. Mr. Barry is covered now by UnitedHealth, one of the nation's largest insurers, but he recently received a notice that it would no longer be available.
''It's really frustrating,'' Mr. Barry said. ''The marketplace here is in a meltdown.''
UnitedHealth is pulling back from Affordable Care Act marketplaces, saying it has lost hundreds of millions of dollars.
Kevin J. Counihan, the chief executive of the federal insurance exchange, said the administration's policy on automatic re-enrollment would promote ''continuity of coverage and the availability of subsidies through the marketplace.''
''We expect most enrollees to actively select a qualified health plan via HealthCare.gov, as they have in prior years,'' Mr. Counihan wrote in a letter to the Wisconsin insurance commissioner, Theodore K. Nickel.
Mr. Nickel objected to the federal policy, saying it could ''sow chaos'' and confusion among consumers, obliging them to pay for insurance chosen by the government. Consumers may be confused when they receive bills from a different insurance company, Mr. Nickel said.
Ben Wakana, a spokesman for the Department of Health and Human Services, said consumers would not be enrolled in any plans without their consent since they would generally have to pay the first month's premium to activate coverage.
Federal officials say consumers should actively shop for a plan in the marketplace and update their income information so subsidies can be properly calculated. In the last open enrollment period, they said, 43 percent of consumers returning to HealthCare.gov switched plans.
Fighting for passage of the Affordable Care Act in 2009-10, President Obama promised that ''if you like your health care plan, you can keep your health care plan.''
But that promise may be difficult to keep in 2017 as major insurers like Aetna, Humana and UnitedHealth leave the public marketplace in many counties and as most of the nonprofit co-ops have collapsed, leaving consumers with fewer choices.
In prior years, if consumers with marketplace coverage did not return to the exchange, they could be enrolled by default in the same plan or a similar plan from the same insurer. Next year, if consumers take no action and no plans are available from their current insurer, they can be placed in a plan from a different insurer.
In reassigning a consumer, the government will try to select a plan similar to the person's current one, but that may not always be possible. Even if a similar plan is available, the insurance company may not have the ability to absorb all of the people being dropped by insurers leaving the market.
Accordingly, federal officials told insurers last month that they would not take enforcement action against health plans that could not meet certain customer-service standards because of a surge in enrollment in 2017. However, they said, health plans must still make reasonable efforts to address consumers' complaints.
Blue Cross and Blue Shield of Minnesota is terminating health plans that cover 103,000 people. Those consumers can shop for coverage, but most of the other carriers are limiting enrollment for 2017. Medica, for example, says it will accept about 7,000 people, in addition to the 43,000 it now insures.
The limits were negotiated with Minnesota's top insurance regulator, Commerce Commissioner Michael Rothman, who wanted to be sure carriers had the capacity to serve new customers.
Molly K. Eckley, 32, of Otter Tail County, Minn., said her family paid $1,100 a month for a Blue Cross and Blue Shield policy covering her, her husband and their two children, ages 5 and 8. With Blue Cross pulling out, she said, ''I am scared for next year.''
Minnesota officials have approved rate increases averaging 50 percent or more for other insurers, and because of the enrollment caps, she said, she felt compelled to choose a plan as fast as possible, before insurers reached their capacity limits.
The Obama administration has developed two new tools to help consumers pick plans, but they will be available in only a few states, as part of a pilot project. Federal officials will try to determine the size of the networks of doctors and hospitals available through health plans in Maine, Ohio, Tennessee and Texas. Provider networks will be labeled ''larger,'' ''smaller'' or ''medium.''
In a separate test, federal officials will assess the quality of health plans in Virginia and Wisconsin, using clinical data and surveys of patients. The quality ratings, on a five-star scale, will be displayed on HealthCare.gov.
URL: http://www.nytimes.com/2016/10/09/us/politics/cant-find-a-plan-on-healthcaregov-one-may-be-picked-for-you.html
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The New York Times
September 29, 2013 Sunday
Late Edition - Final
'Affordable Care' or a Rip-Off?
BYLINE: By ELISABETH ROSENTHAL.
A reporter for The New York Times who is writing a series about the cost of health care, ''Paying Till It Hurts.''
SECTION: Section SR; Column 0; Sunday Review Desk; NEWS ANALYSIS; Pg. 4
LENGTH: 1052 words
IT is no wonder the Obama administration branded its signature health care legislation the Affordable Care Act. For many Americans the basic problem with medicine -- health insurance and health care -- is that it has simply become too expensive, especially in a sluggish economy.
As Americans begin signing up this week to buy insurance, they will begin to test the legislation's tantalizing promise to make health financially viable. Will the policies deliver care at manageable prices, or will ''affordable'' seem like a hollow promotion?
That probably depends a lot on patients' needs, where they live and -- importantly -- their preconceptions of what health insurance is supposed to do, experts say. The insurance marketplaces, or exchanges, will sell four different levels of plan -- bronze, silver, gold and platinum -- with the more expensive plans offering the most extensive benefits. And while premiums for the low-end plans may be relatively cheap, they still require significant out-of-pocket payments, in the form of co-payments and deductibles that could add up to more than $6,000 a year.
''The perception of cost will vary a lot,'' said Dan Mendelson, the chief executive of the consulting firm Avalere Health and a former associate director for health at the federal Office of Management and Budget.
Mr. Mendelson predicted that the plans would be welcomed by people who had wanted to be insured but couldn't obtain or afford insurance because of pre-existing conditions, for example, and for low-income earners who would qualify for heavy subsidies for premiums. ''For some people it will be free, and that is a pretty good value,'' he said.
But the required outlays might seem like a lot of cash to healthy families who previously did without insurance. And they could be downright shocking to patients who last had insurance a decade ago, when health plans tended to require little if any patient payments.
''More of the cost responsibility is being shifted to patients, and more to patients with serious chronic illness,'' Mr. Mendelson said, noting that the silver plans, the second cheapest, are intended to cover only about 70 percent of a patient's medical costs. ''This is different from the concept of insurance we've been carrying around for a long time. So people who sign up for insurance thinking all will be covered are in for some surprises.''
Elisabeth Benjamin, vice president for health initiatives at the Community Service Society of New York, says that -- perceptions aside -- the exchange plans she has vetted in New York State provide consumers a good deal. For a number of years, the group has operated a hot line to help patients troubleshoot their medical bills; 45 percent of callers are uninsured.
''The premium prices are reasonable -- for some people we're talking about as much as my cable bill,'' she said. ''Yes, there are high co-pays, but there's also a cap,'' she added. ''We now have people come to us owing $50,000 or $150,000. So if the worst-case scenario is you pay $5,500, you won't go bankrupt over that.''
Health experts also point out that the larger patient payments required under policies developed for the Affordable Care Act are increasingly a feature of private health care insurance as well.
''We are going through a period of revolution in what health insurance is, from more comprehensive to less comprehensive,'' said Drew Altman, president of the Henry J. Kaiser Family Foundation. In 2006, he said, only about half of employer-provided insurance plans had any deductibles; now 78 percent do.
Insurers impose co-payments and deductibles as an alternative to raising premiums, which are often more tightly regulated. But many health economists approve of the practice because even a small co-pay can push patients to price shop for cheaper care, studies show.
The goal of the new legislation is to make sure everyone has decent health insurance, but that ideal will come at a cost for many Americans. Even though the White House celebrated the fact that premiums released this week by the exchanges in 36 states proved lower than anticipated, those premiums vary tremendously depending on where you live, your age and which plan you choose. For example, the monthly premium for a low-end silver plan for a 40-year-old runs about $300 in many places, but as high as nearly $700 in parts of New York. And monthly premiums are more than $600 for 60-year-olds in some states, although a few states, like New York, charge the same rate regardless of age.
And perhaps more important, all of the plans have significant deductibles and co-payments. Silver plans often do not kick in until the patient has spent $2,000; many states require patients to cover 20 percent of hospital costs and some drugs -- although that cost-sharing is capped at $6,350 per individual, or $12,700 per family, and effectively less for low-income patients.
The Affordable Care Act also includes tens of millions of dollars in spending for patient navigators, who will help patients choose the plan that best suits their needs, and their pocketbooks.
Still, a $2,000 deductible is high compared with plans provided by employers, where the average annual deductible is $1,135, Dr. Altman said.
For those who balk at the new bills, it is useful to remember that those high co-payments are largely a function of the uniquely high price of medical services in the United States -- everything from drugs to scans to operating room time.
In a country where even minor medical procedures cost two or three times more than elsewhere in the developed world, cost-sharing is far more likely to be a burden. A healthy 60-year-old in California with a chronic condition like asthma who needs little more than asthma medicine and an outpatient hernia operation could easily pay $7,000 in premiums plus a $2,250 deductible plus $3,000 for the 20 percent hospital co-pay. When my husband recently developed a blood clot in his leg after a bicycling injury, the generic heparin shots to treat the condition cost $1,400 at the pharmacy. Though the medicine is nothing new, our insurer considered it a specialty drug because of its price. Under some states' silver plans, that would require a 50 percent, or $700, co-pay before getting this potentially lifesaving treatment.
Does that seem affordable, or not?
URL: http://www.nytimes.com/2013/09/29/sunday-review/affordable-care-or-a-rip-off.html
LOAD-DATE: September 29, 2013
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A Key to Costs: Location: Charges for services and drugs will vary by state. Here are costs in silver plans -- the second cheapest of four tiers -- in California, Connecticut, New York and Vermont. (Source: Avalere Health)
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The New York Times
October 5, 2013 Saturday
Late Edition - Final
Shutdown Din Obscures Health Exchange Flaws
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; IN PRACTICE; Pg. 13
LENGTH: 818 words
The shutdown of many federal operations and activities this week has obscured widespread problems in the opening of insurance exchanges under President Obama's health care law, giving the administration time to work out the kinks, members of both parties say.
In a stark contrast, the exchanges -- online markets where consumers can shop for insurance -- opened on Tuesday as much of the government was closing because of an impasse between Mr. Obama and Congressional Republicans over federal spending.
Millions of people were still frustrated Friday when they tried to #GetCovered, as instructed on Twitter by Mr. Obama, Lady Gaga and other celebrities.
Since the federal exchanges opened Tuesday, 8.6 million people have visited its Web site, and its telephone call center has received 406,000 calls, officials said Friday. They declined to say how many people had enrolled in health insurance plans. A section of the Web site where people apply for coverage will be taken down for several hours a day over the weekend so technicians can upgrade its capabilities, the administration said.
The law is at the center of the stalemate that has blocked funds for many federal programs.
Republicans want to repeal or delay it or make major changes, but Mr. Obama refuses to negotiate over the future of the law, which converts coverage from a privilege to a right, starting in January.
Lawmakers and lobbyists say the law's Republican opponents may have overplayed their hand this week, making it easier for supporters to brush aside criticism.
E. Neil Trautwein, a vice president of the National Retail Federation, said the standoff had ''hardened the positions'' of House Republicans, Senate Democrats and the White House, reducing the chances for changes that could make the law more workable for employers.
In general, the law requires larger employers to offer coverage to full-time employees, those who work, on average, at least 30 hours a week. Many employers are lobbying for legislation that would alter the definition and reduce the number of businesses subject to the employer mandate.
Senators Ted Cruz of Texas and Mike Lee of Utah, both Republicans, have led the campaign to strip money from the Affordable Care Act, although many Republican senators have expressed deep reservations about the tactic, saying it is unlikely to succeed.
''This was a self-inflicted wound,'' said one Republican on Capitol Hill, who spoke candidly on the condition of anonymity. ''The push to defund the health care law was ludicrous from the beginning. It had no chance of success. But it became a cause célèbre for the hard right and obscured all the work we had done to investigate and highlight problems with the law.''
On one point, many liberals and conservatives agree. It will be hard to take away government-subsidized coverage once people have it.
At a Tea Party gathering in Texas in August, Mr. Cruz said the president wanted to get people ''hooked on the subsidies, addicted to the sugar.''
''If we get to Jan. 1, this thing is here forever,'' Mr. Cruz said, according to The Texas Tribune.
Ronald F. Pollack, the executive director of Families USA, a liberal-leaning consumer group, said: ''I agree with Senator Cruz. Once people experience the benefits and protections of the Affordable Care Act, it will be hard, if not impossible, to take them away.''
The Obama administration had promoted its Web site for weeks as the best source of information on health insurance. But insurance agents, like consumers, were often stymied when they tried to use it.
''I am president of the National Association of Health Underwriters, and I could not get on the Web site,'' said Thomas M. Harte, a New Hampshire insurance broker who wanted to help clients. ''I have tried more than a dozen times, in the middle of the day and the middle of the night.''
Many users found they could not create the online accounts needed to see what health plans were available.
''The president calls these glitches, a nice poll-tested, fairly benign-sounding word,'' said Senator John Cornyn, Republican of Texas. ''But these were systemic failures of the Obamacare exchanges -- obviously, not ready for prime time.''
Democrats, by contrast, were ecstatic. They said the problems were caused by the unexpectedly high number of visits to the Web site, which showed huge public demand for more affordable insurance.
A few persistent people said they had cleared the hurdles.
Emily R. Wright, 28, a student at East Tennessee State University, said she had signed up for a Blue Cross and Blue Shield policy in about a half-hour, after repeated efforts to get on the Web site. She said she had a painful gynecological condition, endometriosis, and qualified for a subsidy that would halve her premium, to $125 a month.
''I'm thrilled I can get treatment now,'' Ms. Wright said.
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/news/affordable-care-act/2013/10/04/shutdown-din-obscures-health-exchange-flaws/
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The New York Times
February 25, 2016 Thursday
Late Edition - Final
Proof Needed to Enroll in Health Plan Post-Deadline
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 746 words
WASHINGTON -- People who want to buy health insurance in the federal marketplace outside the annual open enrollment period will now have to provide documents to show they are eligible, the Obama administration announced on Wednesday.
In the last two years, insurers say, many people went without coverage and then signed up under the Affordable Care Act when they became sick and needed care. Insurers say that people who sign up after the deadline tend to generate more claims and more costs, raising premiums.
The National Association of Insurance Commissioners, representing state officials, complained recently that ''consumers are not required to provide documentation to substantiate their eligibility for a special enrollment period.''
The new policy requires people to submit documents like a birth or marriage certificate if they want to sign up after the deadline using any of the most common special enrollment periods. These are available after a marriage or the birth or adoption of a child. They are also available when people move permanently to a new address or lose coverage provided by an employer, a government program or other source.
The administration has created more than 30 special enrollment categories and sent emails to millions of Americans last year urging them to see if they might be able to sign up after the open enrollment deadline.
It is unclear how rigorous the government will be in checking eligibility. Consumers who appear to qualify for a special enrollment period will be allowed to obtain insurance while the government tries to confirm eligibility based on the documents provided, federal officials said.
Kevin J. Counihan, the chief executive of the federal marketplace, said Wednesday that the new requirements would apply to people who want to enroll or change health plans midyear in the 38 states that use the federal website, HealthCare.gov.
''We are committed to making sure that special enrollment periods are available to those who are eligible,'' Mr. Counihan said. ''But it's equally important to avoid misuse or abuse.''
If consumers do not provide the required documents, he said, ''they could be found ineligible to enroll in marketplace coverage and could lose their insurance.''
Insurers welcomed the new policy. Clare Krusing, a spokeswoman for America's Health Insurance Plans, a trade group, said the documentation requirements were ''a much-needed step in the right direction.''
Justine G. Handelman, a vice president of the Blue Cross and Blue Shield Association, said the policy could help stabilize the federal insurance marketplace. The insurer Aetna said that, on average, people who signed up in a special enrollment period kept their coverage for about half of the time of regular enrollees.
Consumer advocates who usually support the White House denounced the administration's action. Rachel Klein, the director of organizational strategy at Families USA, a consumer group, said, ''We should be making it easier for people to sign up for health insurance, not harder.''
Consumers, she said, are still learning how to navigate a complex enrollment process, so the administration should not be putting ''bureaucratic roadblocks'' in their path.
Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group, said she was disappointed because the government was imposing the new requirements without clear evidence of abuse.
''There is evidence that special enrollment periods are underutilized,'' Ms. Solomon said. ''We fear that requiring more paperwork will exacerbate that trend and keep people out of coverage.''
The new policy was announced a few hours after the Government Accountability Office, an investigative arm of Congress, questioned another aspect of HealthCare.gov.
In a report to Congress, the investigators said that the Centers for Medicare and Medicaid Services ''has assumed a passive approach to identifying and preventing fraud'' by people who bought insurance and obtained subsidies through HealthCare.gov.
The Obama administration waived certain document filing requirements, did not always verify income and citizenship, and thus ''allowed an unknown number of applicants to retain coverage, including subsidies, they might otherwise have lost,'' the report said.
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URL: http://www.nytimes.com/2016/02/25/us/politics/proof-needed-to-enroll-in-affordable-care-act-health-plan-post-deadline.html
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The New York Times
March 31, 2017 Friday
Late Edition - Final
Health Subsidies for Low Earners Will Continue to Year's End, House G.O.P. Says
BYLINE: By ROBERT PEAR and REED ABELSON; Robert Pear reported from Washington, and Reed Abelson from New York.
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 1028 words
WASHINGTON -- Senior House Republicans said Thursday that they expected the federal government to continue paying billions of dollars in subsidies to health insurance companies to keep low-income people covered under the Affordable Care Act for the rest of this year -- and perhaps for 2018 as well.
The decision would be a curious twist for Republicans who have spent seven years battling President Barack Obama's health law only to fail last week to repeal it. The Republican-led House won a lawsuit accusing the Obama administration of unconstitutionally paying the insurance-company subsidies, since no law formally provided the money.
Although that decision is on appeal, President Trump could accept the ruling and stop the subsidy payments, which reduce deductibles and co-payments for seven million low-income people. If the payments stopped, insurers -- deprived of billions of dollars -- would flee the marketplaces, they say. The implosion that Mr. Trump has repeatedly predicted could be hastened.
But senior Republicans appear unwilling to force that outcome.
''While the lawsuit is being litigated, then the administration funds these benefits,'' the House speaker, Paul D. Ryan, said Thursday. ''That's how they've been doing it, and I don't see any change in that.''
The future of the cost-sharing payments has been unclear since the House, in a setback for Mr. Trump and Mr. Ryan, failed on Friday to pass a bill to repeal the 2010 health care law, a centerpiece of Mr. Obama's legacy.
Representative Greg Walden, Republican of Oregon, who is the chairman of the Energy and Commerce Committee, said Thursday, ''I will do everything I can to make sure that the cost-sharing reduction payments get made.''
''That's an obligation we have not only to the insurers,'' but also to consumers who enrolled in plans under the health care law, Mr. Walden said. ''We cannot leave them high and dry.''
Mr. Walden said his preference was for Congress to appropriate the money, about $7 billion a year. That is ''the best legal way to do it,'' he said.
At the same time, Mr. Ryan said the House would pursue the litigation to vindicate its ''power of the purse.''
''We don't want to drop the lawsuit because we believe in the separation of powers,'' Mr. Ryan said. ''We believe in Congress retaining its lawmaking power.''
Judge Rosemary M. Collyer of Federal District Court in Washington ruled for the House in May, but allowed the subsidy payments to continue, pending resolution of an appeal by the Obama administration. The Trump administration has not taken a position on the appeal.
The Justice Department has strong institutional reasons for objecting to the court decision: It contends that Congress should not be able to ''call upon the courts to referee a dispute'' with the executive branch of the federal government.
Insurers have lost hundreds of millions of dollars on business under the Affordable Care Act and are pulling back from the public marketplaces in many states, creating a possibility that some consumers will have no options on the insurance exchanges next year.
Senators Lamar Alexander and Bob Corker, Republicans of Tennessee, introduced a bill this week to protect such consumers.
''Urgent action is needed,'' Mr. Alexander said. ''In the Knoxville area where I live, the one remaining insurance company on the Affordable Care Act exchange has pulled out for the year 2018. So it is a near certainty that there will be zero insurance options for Tennesseans who live there and buy their insurance on the exchange.''
The uncertainty about the intentions of the Trump administration and Congress has made insurers jittery, and Wall Street analysts are watching closely to see if insurance companies will leave more markets.
David Windley, a securities analyst at Jefferies L.L.C., said enrollment would probably plummet without the cost-sharing subsidies because so many people rely on them. If the subsidies go away, he said, ''all bets are off.''
Mr. Windley, who met recently with a senior executive of Anthem, the insurance giant, told investors on Thursday that he believed that the company was ''leaning toward exiting'' a large percentage of the local markets where it now participates. That news was first broken by Bloomberg News.
Anthem officials refused to comment. The company has previously threatened to leave if the government does not take certain steps to stabilize the market.
A departure by Anthem, already the sole carrier in a third of the counties in states where it operates, could be a devastating blow to the market. The company, which offers plans in 14 states, is a major player, and its exit would follow the departure of other large insurers like UnitedHealth Group, Aetna and Humana.
But Anthem is not likely to make its decision lightly. Because it operates Blue Cross and Blue Shield plans, which have historically been the main insurer in many states, it has strong ties to the individual market. Still, other Blue Cross plans have left some markets, and other for-profit companies have not hesitated to leave.
''The precedent for backing away is established,'' Mr. Windley said.
Mr. Ryan met on Thursday with leaders of a dozen conservative groups to map strategy for possible further efforts to repeal the Affordable Care Act.
''We told the speaker that we think we can find the votes needed to pass this bill,'' Grover G. Norquist, the president of Americans for Tax Reform, said in an interview. ''We are optimistic. The speaker said, 'This is still doable, and it's our goal to get it done while we work on tax reform on a parallel path.'''
Mr. Ryan is encouraging members of his conference to patch up their differences. But the collapse of the bill last week, torpedoed both by the conservative Freedom Caucus and by more moderate Republicans, left deep fissures in the House Republican Conference.
''We are frustrated and disappointed,'' said Representative Chris Collins of New York, who supported the bill and is close to Mr. Trump. ''But it's not outright warfare.''
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URL: http://www.nytimes.com/2017/03/30/us/politics/health-insurance-republicans.html
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The New York Times
December 27, 2016 Tuesday 00:00 EST
How a Budget Chief Can Wreak Havoc;
What's at Stake
BYLINE: THE EDITORIAL BOARD
SECTION: OPINION
LENGTH: 644 words
HIGHLIGHT: As head of the O.M.B., Mick Mulvaney would have the power to advance or impede federal regulation.
Mick Mulvaney, the Republican congressman and fiscal hawk nominated by Donald Trump to head the White House Office of Management and Budget, will, if confirmed, be in charge of creating and promoting Mr. Trump's federal budgets, a position that would put him at the center of debates within the administration and with Congress over the president's priorities. As the O.M.B. director, Mr. Mulvaney would also have power to advance or impede federal regulation, because many proposed rules have to pass muster at O.M.B. before they are issued.
The traits Mr. Mulvaney brings to the job include a pronounced hostility to both federal spending and federal regulation - the basics of functional government. He rode the anti-deficit, anti-regulation Tea Party wave into Congress in 2010 and is a founder of the far-right House Freedom Caucus.
In recent years, he has advocated shutting down the government rather than passing legislation to keep the nation and the economy running, and he was one of several dozen House Republicans who refused to back a deal to avoid default on the national debt by raising the statutory debt limit. In 2013, he nearly torpedoed a $50.7 billion relief bill in the wake of Hurricane Sandy by pressing for draconian spending cuts to offset the emergency funds. He has voted many times to repeal the Affordable Care Act, calling it a "government takeover" of health care.
Because all policies affect the budget, all policies, directly or indirectly, fall into the O.M.B.'s purview at some point. Mr. Mulvaney would thus play an important role in decisions about how to dismantle the Affordable Care Act, a Republican priority. He would also have a voice in discussions over Mr. Trump's infrastructure plan. As a sworn enemy of government spending, it seems likely he would prefer to finance the plan by giving tax cuts to private developers rather than sending federal money to the states - a move that would create windfall profits for a few private businesses without adequately meeting public infrastructure needs.
On regulatory actions over which the O.M.B. has a say, there is every reason to believe that Mr. Mulvaney, serving in a Trump administration, would water down or indefinitely delay proposed rules. During his time in Congress, he has supported regulatory rollback efforts, including legislation to strip President Obama of executive rule-making authority. The rules over which the O.M.B. has influence include energy and environmental standards, labor protections and food safety.
An unanswered question is how a deficit foe like Mr. Mulvaney could actually get behind the Trump economic agenda. Mr. Trump has proposed tax cuts that would cost $6.2 trillion over 10 years, according to estimates by the nonpartisan Tax Policy Center. On top of those cuts, he has proposed vast new spending on defense and infrastructure. The combination of tax cuts and new spending would result in a huge increase in federal debt - which Mr. Trump and Mr. Mulvaney could cite as an excuse to make devastating spending cuts to other federal programs and services.
Or Mr. Mulvaney could sign off on reckless budgets by pushing for rosy economic assumptions that can make it seem as if revenues will rise and deep deficits will disappear. Budget directors can also employ the "magic asterisk" (popularized by David Stockman, the budget director for President Ronald Reagan), which is used to denote unspecified budget cuts that will someday, somehow offset projected deficits.
At this juncture, it is impossible to know how Mr. Mulvaney will get Mr. Trump's numbers to add up. But it is safe to assume that if he does pull off that trick, the results won't bode well for effective government.
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How a Budget Chief Can Wreak Havoc
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Mick Mulvaney, the Republican congressman and fiscal hawk nominated by Donald Trump to head the White House Office of Management and Budget, will, if confirmed, be in charge of creating and promoting Mr. Trump's federal budgets, a position that would put him at the center of debates within the administration and with Congress over the president's priorities. As the O.M.B. director, Mr. Mulvaney would also have power to advance or impede federal regulation, because many proposed rules have to pass muster at O.M.B. before they are issued.
The traits Mr. Mulvaney brings to the job include a pronounced hostility to both federal spending and federal regulation -- the basics of functional government. He rode the anti-deficit, anti-regulation Tea Party wave into Congress in 2010 and is a founder of the far-right House Freedom Caucus.
In recent years, he has advocated shutting down the government rather than passing legislation to keep the nation and the economy running, and he was one of several dozen House Republicans who refused to back a deal to avoid default on the national debt by raising the statutory debt limit. In 2013, he nearly torpedoed a $50.7 billion relief bill in the wake of Hurricane Sandy by pressing for draconian spending cuts to offset the emergency funds. He has voted many times to repeal the Affordable Care Act, calling it a ''government takeover'' of health care.
Because all policies affect the budget, all policies, directly or indirectly, fall into the O.M.B.'s purview at some point. Mr. Mulvaney would thus play an important role in decisions about how to dismantle the Affordable Care Act, a Republican priority. He would also have a voice in discussions over Mr. Trump's infrastructure plan. As a sworn enemy of government spending, it seems likely he would prefer to finance the plan by giving tax cuts to private developers rather than sending federal money to the states -- a move that would create windfall profits for a few private businesses without adequately meeting public infrastructure needs.
On regulatory actions over which the O.M.B. has a say, there is every reason to believe that Mr. Mulvaney, serving in a Trump administration, would water down or indefinitely delay proposed rules. During his time in Congress, he has supported regulatory rollback efforts, including legislation to strip President Obama of executive rule-making authority. The rules over which the O.M.B. has influence include energy and environmental standards, labor protections and food safety.
An unanswered question is how a deficit foe like Mr. Mulvaney could actually get behind the Trump economic agenda. Mr. Trump has proposed tax cuts that would cost $6.2 trillion over 10 years, according to estimates by the nonpartisan Tax Policy Center. On top of those cuts, he has proposed vast new spending on defense and infrastructure. The combination of tax cuts and new spending would result in a huge increase in federal debt -- which Mr. Trump and Mr. Mulvaney could cite as an excuse to make devastating spending cuts to other federal programs and services.
Or Mr. Mulvaney could sign off on reckless budgets by pushing for rosy economic assumptions that can make it seem as if revenues will rise and deep deficits will disappear. Budget directors can also employ the ''magic asterisk'' (popularized by David Stockman, the budget director for President Ronald Reagan), which is used to denote unspecified budget cuts that will someday, somehow offset projected deficits.
At this juncture, it is impossible to know how Mr. Mulvaney will get Mr. Trump's numbers to add up. But it is safe to assume that if he does pull off that trick, the results won't bode well for effective government.
Follow The New York Times Opinion section on Facebook and Twitter (@NYTOpinion), and sign up for the Opinion Today newsletter.
URL: http://www.nytimes.com/2016/12/27/opinion/how-a-budget-chief-can-wreak-havoc.html
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Health Care Under Donald Trump;
Letters
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HIGHLIGHT: Readers discuss the challenges Republicans will face with their promise to repeal and replace Obamacare.
Readers discuss the challenges the G.O.P. will face with its promise to replace Obamacare.
To the Editor: Re "A G.O.P. Plan on Health Act: Rescind Slowly" (front page, Dec. 3):
This article is just the latest indication that health care legislation is going to be a huge problem for Republicans. As the former chief executive of John Hancock Insurance Company, which once sold health insurance, I think it is fair to say that health insurance sold on an individual basis is a difficult proposition no matter how it is done.
If it is sold like any other product, people with pre-existing or chronic conditions will be turned down or will not be able to afford it. If exceptions are made, insurance companies will struggle to make a profit. None of the ideas being trotted out for the "replace" portion of the "repeal and replace" have much effect on the basic problem. This is not to say Obamacare is great; it isn't. As one example, the penalty for not buying insurance was much too low. However, the idea of repealing before knowing exactly what will replace it is a recipe for chaos for everyone involved.
Republicans are also spending far too little time on trying to deal with the underlying problem of costs. A couple of suggestions: How about requiring hospitals to publish their prices, and allowing Medicare to negotiate drug prices (which Donald Trump backed as a candidate)?
STEPHEN BROWN
Palm Beach, Fla.
To the Editor: This is some of the nuttiest, ill-thought-out political rationalizing I have ever seen. According to this article, Republicans plan to strip out the mandate and tax penalties in Obamacare, leaving the remainder to deal with later.
President Obama's handling of the Affordable Care Act was among the most artless, bungled bits of leadership in recent history. To order significant parts of the population to buy something they didn't think they needed or could afford and then slap them with a penalty for not doing it before getting their buy-in was amateurish in the extreme. That doesn't change the fact that a mandate was essential for creating a working risk pool. Then delaying enforcement of the mandate made escalation of premiums inevitable, further strengthening the argument that the plan was flawed. But Republicans will not be able to devise a workable, affordable insurance program without a mandate. It is simple mathematics.
While Republicans play petty politics and twist themselves into pretzels just to vent their petulant resentment against Barack Obama, millions of people's lives are being toyed with, and we watch in horror a charade of governing by people without the least idea of what they are doing.
ROBERT MILLSAP
Woodland, Calif.
To the Editor: While Republicans in Congress debate "repeal and replace" health care for millions of us, what about their guaranteed health care? That's an entitlement program to question. Why do members of Congress have better guaranteed health care than the people whom they represent? Let's ask them how they would like the changes they are considering proposing for us. Would they like their health care insurance program repealed and gradually replaced? Would they enjoy health savings accounts? If they were not re-elected, they might need to seek another job. Would they want their pre-existing conditions to possibly not be covered by their next insurer?
BARBARA ELER
New Milford, Conn.
To the Editor: It's the height of hypocrisy for the House majority leader, Kevin McCarthy, to complain of Democrats "playing politics" with Obamacare and to call for good-faith negotiation. Republicans had the opportunity for this discussion in 2009 when President Obama articulated his openness to any proposal that expanded coverage without adding to the debt. They could readily have obtained many of the adjustments they now propose had they been willing to engage at that time. Instead they opted for calculated party-line opposition focused entirely on handing the president a political defeat, and outrageous anti-Obamacare hyperbole has poisoned the discussion in the years since.
By all means let's stop playing politics, but this means abandoning the overheated and vacuous repeal rhetoric and engaging in good-faith discussion on possible adjustments to the existing framework, not playing chicken with the coverage for millions of people.
STEVE LEOVY
Boulder, Colo.
To the Editor: "Why It Will Be Hard to Repeal Obamacare" (nytimes.com, Dec. 3) lays out the obstacles in undoing the Affordable Care Act. It explains how the G.O.P.'s restructuring of Obamacare could bring chaos to America's health insurance industry, not to mention the millions of Americans whose health and quality of life would be compromised.
Chaos doesn't come cheap. The operational costs alone to implement the changes bandied about by Speaker Paul Ryan and Tom Price, the nominee to head Health and Human Services, would be staggering. Every state would be affected, many of which are still upgrading their state-funded and federally subsidized programs to accommodate Obamacare policies.
A bit of prognostication: Since Paul Ryan's "repeal and replace" approach to Obamacare has morphed into "repeal and delay," the "repeal" bills will pass easily in both the Senate and the House. But the Republicans are nowhere near coming up with the "replace" part. Congressional Democrats, in contrast to the last eight years, will and should be the obstructionists.
RICH AVILLA
Sequim, Wash.
The writer has been an analyst and senior consultant on state Medicaid programs and federal projects with the Center for Medicare and Medicaid Services.
To the Editor: From the start it's been clear that the best-known and most valued parts of Obamacare are (A) features like prohibiting penalties for pre-existing conditions and allowing people to remain on their parents' policies until age 26.
It's been equally clear that the most troublesome parts are (B) forcing people to buy health insurance, paying for the subsidies the system requires and keeping health care costs down.
So the Democrats will get credit for (A), provisions that are now too popular for the Republicans to repeal, while the Republicans in their pending health care redesign will be saddled with the problems that (B) will entail. Chalk one up for President Obama.
ANTHONY M. PAUL
Coral Gables, Fla.
To the Editor: There is a simple solution to the Republican quandary over repealing Obamacare while keeping many of its provisions: Pass a law renaming it Trumpcare. Problem solved.
CLAUDE FISCHER
Berkeley, Calif.
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Should I Lie About My Beliefs to Get Health Insurance?
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June 28, 2012 Thursday
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HIGHLIGHT: President Obama offered a brief but intense defense of the embattled law, selling its major provisions as important reforms and the mandate as "essential."
President Obama hailed the Supreme Court's decision on the Affordable Care Act, saying the politically divisive measure will improve health care for millions of Americans who have insurance and expand coverage to millions who do not.
Speaking in the East Room, Mr. Obama offered a brief but intense defense of the embattled law, selling its major provisions as important reforms. He said the court's decision to let the law stand will allow those changes to go forward.
"Whatever the politics, today's decision was a victory for people all over this country," Mr. Obama said as he listed the law's major provisions. "Thanks to today's decision, all of these benefits and protections will continue."
Mr. Obama did directly confront the issue of the insurance mandate in the health care law, noting that he did not initially support the idea. But he said that despite being politically unpopular, it is essential to the legislation.
"People who can afford to buy health insurance should take the responsibility to do so," Mr. Obama said. He also noted that the mandate provision has been supported in the past by Republicans, including, he said without referring to Mitt Romney by name, the presumed Republican presidential nominee.
Mr. Obama pledged to continue to carry out the law, but said the country should turn its attention back to concerns about the economy.
"What we won't do, what the country can't afford to do, is refight the political battles of two years ago," he said. "Now's the time to keep our focus on the most urgent challenge of our time, putting people back to work."
He added that when people look back in five years, he was confident that they would conclude that "we'll be better off because we had the courage to pass this law and keep moving forward."
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June 28, 2012 Thursday
Seven Consequences of the Health Care Ruling
BYLINE: JAMES A. MORONE
SECTION: OPINION
LENGTH: 1134 words
HIGHLIGHT: The Supreme Court's blockbuster decision on Thursday has consequences that will reverberate for years.
"I have had some bitter disappointments as president,"Harry S. Truman wrote in his memoirs, "but the one that has troubled me most, in a personal way, has been the failure to defeat the organized opposition to a national compulsory health insurance program." He was just the first in a long line of presidents stymied by health reform. NowBarack Obama has succeeded where his predecessors failed. Or has he?
The Supreme Court's blockbuster decision on Thursday has consequences that will reverberate for years. Here are seven big ones.
The United States does not have national health insurance for a not-so-simple reason: Congress. The people elect presidential candidates who promise the reform. Congress, through the years, has said, no thanks. It is so difficult because it takes 60 votes in the Senate and tight discipline in the House. By climbing so visibly into the fray, the court served notice that it would become an active part of the process. Yes, the Democrats won - this time. But the decision was close, technical and studded with new barriers to Congressional action on profound challenges that remain. More than 15 million Americans are still uninsured, even with the health reform; the cost of drugs, devices and procedures continues to spiral; worsening inequality has exacerbated enormous differences in health outcomes. Future health reforms will take 60 votes in the Senate and 5 on the bench.
The court was drifting into perilous territory. A polite fiction long justified the idea of nine unelected justices overruling Congress and the states: They merely interpret the law. That fiction had been slipping badly ever since Bush v. Gore in 2000. A recent New York Times survey found that three-quarters of the public believed that politics was a frequent factor in court decisions. Political scientists have lots of studies showing just that. Striking down the signal achievement of this administration on a straight party-line vote would have put the court deeper into dangerous territory, with liberals gradually signing up for the longstanding conservative effort to curb the Supreme Court's powers - perhaps by limiting terms to 15 years, for example. With his exquisitely complicated ruling - siding with the liberals on taxing powers, not on the interstate commerce clause - the chief justice restored the idea that the court is wrestling with the complicated tangle of law - not punching in a partisan vote. In the process, he slipped the health care issue right back to where it belongs: before the voters.
. Very quietly, the Affordable Care Act introduced a revolutionary change: All poor people in America would get Medicaid. The new law would have extended Medicaid to everyone with incomes up to 133 percent of the federal poverty line ($23,050 a year for a family of four). Aren't the poor already covered? That depends on where they live. In New York, most adults up to 150 percent of the poverty line are covered; in Texas, Medicaid reaches only to 26 percent of the poverty line - a family of four is not eligible if they earn, say, $9,000 a year. The court ruled that Congress may not require states to expand Medicaid. States can stick to their old Medicaid programs. Stingy states may choose to stay stingy. That part of the decision flew under the media radar. But it is a significant blow to liberals who had a simple way to grow benefits by expanding programs.
When Truman put national health insurance in play, he did something bizarre. He refused to argue for it. While opponents cried "socialism," Truman remained mum. That silence became a not so proud Democratic legacy. As soon as Mr. Obama proposed the legislation, opponents began repeating "death panels," "taxes" and "government takeover"; the Democrats responded by getting down into the policy weeds of their complicated law. The president's statement on Thursday was a case in point. Down the checklist he went: policy details, moving story, pivot to the economy. When you say health reform, my summer neighbors in New Hampshire all nod their heads and say "death panels." The question for Obama and the Democrats: What do you have that will match that? If they don't come up with something stirring, the reform that survived the court could be lost in the election.
When the Clinton health reform went down to defeat in 1994, something curious happened. The health care system ran with many of the reforms that the Clintons had recommended. The managed-care revolution sprang from the failed reform. The Obama reform promises even greater changes: new incentives for hospitals to deliver more efficient care, new incentives to nudge physicians into primary care, and powerful new rules to stop insurance companies from cherry-picking the people they cover. The court gave the hospitals, doctors and insurance companies a green light to run with these changes. In many cases, they will. The medical system is going to change regardless of whatMitt Romney might do in his first week in office.
Republicans have their campaign slogan: Repeal and replace! But history has a funny lesson for them. Every Republican administration in the past 60 years has proposed health care reform. There is no escaping it. What is the next Republican administration's health care policy going to look like? There are plenty of popular provisions in the Affordable Care Act. The party of "hell, no" might be wise to think of ways to remake the law in its own image. Repeal may sound good now, but history is unambiguous. An administration without a health policy will soon be vulnerable to attacks. Cruel! Unfeeling! Out of touch! A quiet Republican conversation about what to cut, what to keep, and what to change will pay big dividends in the future.
The Supreme Court weakened a major prop of classical liberalism: the interstate commerce clause. When Congress passed the blockbuster Civil Rights Act of 1964, it relied on its interstate commerce powers. Even an Alabama barbecue shack with a local clientele could not discriminate against blacks; after all, it served food that came from out of state. The Supreme Court this week backed way off from that expansive reading of the commerce clause. Mainstream Democrats looking to expand social welfare policies have gotten lazy: they've recycled Republican ideas -Bill Clinton borrowed fromRichard M. Nixon the idea of building on employer-based private insurance to achieve national coverage, and Barack Obama borrowed from Republicans like Senator John Chafee of Rhode Island the idea of mandating individual coverage to broaden the private insurance pool. It's high time for the Democrats to get more creative.
How Obama Can Win Ohio Again
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Forget the Money, Follow the Sacredness
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April 27, 2017 Thursday
Late Edition - Final
Anthem Threatens to Leave Health Exchanges if Patient Subsidies Are Ended
BYLINE: By REED ABELSON; Katie Thomas contributed reporting..
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Even as Anthem, one of the nation's largest insurers, reported an improved financial picture for the last year, the company warned on Wednesday that it would consider leaving some federal health care marketplaces or raising its rates sharply if the government does not continue subsidies to help low-income people.
Joseph R. Swedish, the company's chief executive, set a deadline of early June for a decision on the subsidies, saying Anthem would weigh increasing rates by at least 20 percent next year.
These subsidies, called cost-sharing reductions because they reduce the amount people must pay out of pocket when they go to the doctor, have become a political football as President Trump and House Republicans try to repeal the federal health care law and negotiate a spending bill with a deadline looming this week.
While Republicans successfully sued the Obama administration to discontinue funding the payments, the decision is on appeal, and Mr. Trump has recently indicated that he wants to use the subsidies as a bargaining chip with Democrats.
On Wednesday, Republican leaders were seeking to assure Democrats that the subsidies would continued to be funded, although there was no guarantee.
If the subsidies ended in 2018, the lack of funding ''would cause further market instability,'' Mr. Swedish said, which would make the company's participation in the federal market ''even more challenging.''
While the Republican-controlled Congress and President Trump insist that the markets under the Affordable Care Act have been ''imploding,'' Anthem's earnings report on Wednesday offered another sign that some markets were stabilizing.
By adding new customers and raising prices, Anthem said its overall profits reached $1 billion on higher revenue of about $22 billion, beating Wall Street expectations and sending its stock higher on Wednesday. Its shares closed at $179.03, an increase of 3.8 percent.
Anthem, which operates for-profit Blue Cross plans in 14 states, is the latest insurer to say its performance has improved over the past year in the individual markets created under the Affordable Care Act. The company said it now covered 1.1 million people through the state marketplaces or exchanges, with an additional 500,000 customers buying individual policies under the law.
The company is deciding where to sell policies and what to charge for 2018, and it is telling state insurance regulators that it will need to make significant adjustments to its offerings if the government funding remains unclear by early June.
While Mr. Swedish praised some of the steps that have been taken to stabilize the markets, he also urged the Trump administration and Congress to eliminate the tax on health insurance as a way of keeping premiums lower and to create a reinsurance program or high-risk pool to help insurance companies pay claims for people with very high medical expenses.
Another for-profit insurer that has a major presence in the market, Centene, announced its results on Tuesday. The company expressed confidence that there was support from both Republicans and Democrats for the subsidies and said it expected to remain in the market.
Like many other insurers, Anthem has struggled to make money in the marketplaces, but it said it expected to break even or do better this year.
Two independent analyses, from the Kaiser Family Foundation and Standard & Poor's, suggested that the markets over all were stabilizing despite the claims from Mr. Trump and congressional Republicans that they were collapsing. But there have been recent exits by high-profile insurers like Aetna and Humana, and there is concern that some places could be without an insurer to sell individual policies under the law. Other markets may have only a single insurer offering coverage.
Anthem's results seemed to bolster the view that the remaining insurers were turning the corner, although significant uncertainty remained, said Gary Claxton, a Kaiser vice president who was one of the authors of the recent report.
Anthem also addressed questions about its pharmacy benefit manager, the company that handles the drug claims for its customers. This week, that company, Express Scripts, said it would most likely lose Anthem, its largest customer, beginning in 2020, a significant blow. Anthem accounted for more than $17 billion of Express Scripts' annual revenue. In the first quarter of this year, Anthem accounted for 18 percent of Express Scripts' business.
Last year, the two companies engaged in a bitter legal battle in which Anthem sued Express Scripts for $15 billion and claimed the company had been overcharging it for drugs.
In comments this week on CNBC, Express Scripts' chief executive, Timothy C. Wentworth, said he would like to keep Anthem's business, adding, ''We've given them terrific service.''
In its call with investors, Anthem seemed to suggest that it had not decided which company it would pick to handle its drug business. ''We've not made a final decision with respect to any vendor,'' Mr. Swedish said. ''We've not ruled anyone in or out.''
The company said it would evaluate its options and make a decision by the end of the year. Mr. Swedish said he hoped that the two companies would reach an amicable resolution on Anthem's lawsuit.
Mr. Swedish also discussed Anthem's proposed $48 billion merger with Cigna, another large health insurer. In February, a federal judge blocked the merger after the Justice Department challenged the combination as being harmful to consumers, one of two mergers of insurance giants that it successfully challenged. Anthem and Cigna have had a fraught relationship, but Anthem is appealing the decision and said it expected a ruling soon on whether the merger could proceed.
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GRAPHIC: PHOTO: President Trump with insurance executives including Joseph R. Swedish, left, Anthem's chief executive, in February. Mr. Trump has said he may try to end subsidies helping low-income people. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES)
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Republicans Cite Health Care Ruling in Pushing Candidacies
BYLINE: ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 442 words
HIGHLIGHT: Rick Perry and Marco Rubio were among the first Republican presidential candidates to react to the Supreme Court’s ruling to uphold Affordable Care Act subsidies.
Republican presidential candidates were quick to pivot off the Supreme Court's ruling to uphold Affordable Care Act subsidies, arguing that the decision shows the need to replace President Obama with a member of their party.
Former Gov. Rick Perry of Texas said that it should not be left to the Supreme Court to "save us from Obamacare."
"We need leadership in the White House that recognizes the folly of having to pass a bill to know what's in it," Mr. Perry said. "We need leadership that understands a heavy-handed, one-size-fits-all policy does nothing to help health outcomes for Americans."
Senator Marco Rubio of Florida said the court erred in trying to correct Mr. Obama's mistakes. The decision was another reason that he should be elected president, Mr. Rubio said.
I remain committed to repealing this bad law and replacing it...
- Marco Rubio (@marcorubio) June 25, 2015
Gov. Scott Walker of Wisconsin said the decision should be more motivation for Congress to overturn the law.
"Today's Supreme Court ruling upholding the administration's implementation of Obamacare means Republicans in the House and Senate must redouble their efforts to repeal and replace this destructive and costly law," he said.
Senator Rand Paul of Kentucky said he was the man to lead the overturn of the law.
"This decision turns both the rule of law and common sense on its head," Mr. Paul said in a statement. " As president, I would make it my mission to repeal it, and propose real solutions for our health care system."
Former Gov. Jeb Bush of Florida said that if he becomes president, he will make fixing the health system through the private sector a top priority.
"We need to put patients in charge of their own decisions, and health care reform should actually lower costs," Mr. Bush said. "Entrepreneurs should be freed to lower costs and improve access to care - just like American ingenuity does in other sectors of the economy. "
The Republican National Committee decided to focus its statement not on Mr. Obama, but on Hillary Rodham Clinton and the 2016 election.
"Today's ruling makes it clear that if we want to fix our broken health care system, then we will need to elect a Republican president with proven ideas and real solutions that will help American families," said Chairman Reince Priebus. "Hillary Clinton supports big government mandates and expanding the government's reach into our health care system, maneuvers that have made our health care system worse off."
The statement made no direct reference to Mr. Obama.
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March 12, 2014 Wednesday
Late Edition - Final
Health Care Enrollment Falls Short of Goal, With Deadline Approaching
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 992 words
WASHINGTON -- Almost a million people signed up last month for private health insurance under the Affordable Care Act, federal officials said Tuesday, bringing the total to date to 4.2 million but leaving the Obama administration well short of its original goal, with less than a month to go before the end of the open enrollment period.
White House officials predict a surge in sign-ups just before the six-month enrollment period ends on March 31, but it will be a challenge to make up for the slow start that resulted from technical problems crippling the federal insurance marketplace in October and much of November.
The administration said Tuesday that 943,000 people signed up for coverage last month, down from 1.1 million in January and 1.8 million in December. Officials noted that February was a short month, with fewer days for people to apply.
Administration officials said they were pleased with the pace of enrollment, even though the total fell short of the target initially set by the Department of Health and Human Services. In an internal memorandum in September, federal health officials said they wanted to have 5.6 million people enrolled by the end of February, with a total of seven million signed up by the end of this month. The goal for February alone was 1.3 million.
Of those who signed up in February, the administration said, 27 percent were between 18 and 34, up slightly from the 25 percent for the first four months of the enrollment period, through January.
Insurers and the White House have avidly sought young adults, saying their premium payments were needed to offset the costs of coverage for Americans who were older and presumably needed more care. The age profile of people signing up is somewhat older than many insurers expected, with the number of those between 55 and 64 -- 1.3 million -- exceeding the number in the 18-to-34 age bracket, 1.1 million.
The latest figures were released as the White House makes a final push to increase enrollment, with a particular focus on young adults, Latinos and African-Americans.
''As more Americans learn just how affordable marketplace insurance can be, more are signing up to get covered,'' said Kathleen Sebelius, the secretary of health and human services. Experience with other health programs shows that ''young adults tend to sign up later in the process,'' she added.
However, Brendan Buck, a spokesman for the House speaker, John A. Boehner, said young adults were concluding that the health care law was a bad deal. ''Given these dismal enrollment numbers,'' he said, ''the president needs to work with Congress to get rid of this year's individual mandate penalty.''
Julie Bataille, a spokeswoman for the federal Centers for Medicare and Medicaid Services, predicted that ''millions more Americans will enroll'' before the deadline, and she said, ''We have no plans to extend the open enrollment period.''
Four years after it was signed by President Obama, the Affordable Care Act remains a divisive political issue, and it already figures prominently in many midterm election campaigns.
Democrats hope that public opinion will swing in favor of the law as more people experience its benefits. But Republicans continually hammer at the law, saying it will drive up premiums, cause the cancellation of insurance policies for some families and increase costs for many businesses.
Mr. Obama has delayed many provisions, reducing political risks for Democrats this fall but guaranteeing that the law will be hotly debated for several more years at least.
The White House and its allies have been running a campaign-style effort to encourage enrollment. In recent weeks, Ms. Sebelius has been in Arizona, Florida and Texas, among other states.
Of the people who have signed up so far, the administration said, 2.6 million were in the federal insurance marketplace, and 1.6 million were in states running their own exchanges.
California and New York accounted for two-thirds of all sign-ups through February in the 14 states running their own exchanges. California had 869,000 sign-ups, nearly twice as many as any other state, and New York had 244,600. By contrast, in Hawaii, where the state-run exchange has had serious troubles, fewer than 5,000 people were reported as having signed up.
Large numbers of people used the federal exchange to sign up for insurance in Florida (442,000), Texas (295,000) and North Carolina (200,500).
The new report does not show how many people have paid premiums, as they generally must to activate coverage. Nor does it show if many of those selecting health plans were previously uninsured, or how many signed up for a plan, then canceled it and chose another. Officials said they did not have reliable data on the race or ethnic origin of people signing up.
Insurers say that roughly one in five people who signed up for coverage failed to pay January premiums. And some of those who paid and received services in January failed to pay premiums for February, putting their coverage at risk.
More than four-fifths of those choosing health plans to date -- 83 percent -- qualified for financial assistance to help pay their premiums, administration officials said.
People who go without insurance after March 31 may be subject to tax penalties. The Internal Revenue Service can deduct the penalties from any refunds to which taxpayers may be entitled.
Brian Haile, a senior vice president of Jackson Hewitt Tax Service, said his colleagues had helped tens of thousands of people file applications for insurance subsidies or Medicaid in the last two months.
''There's a tremendous amount of confusion about the computation of penalties for people who go without insurance,'' Mr. Haile said. ''While some people may be exempt and others will have a penalty as low as $95 a person, the penalty may be substantially higher, depending on your income. Many people are pleasantly surprised to find that they are eligible for free or low-cost coverage.''
URL: http://www.nytimes.com/2014/03/12/us/almost-a-million-more-sign-up-for-health-coverage-in-february.html
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GRAPHIC: CHARTS: Signing Up for Insurance, But Well Below Targets: About 943,000 people signed up for private insurance in federal and state exchanges in February, bringing the total to 4.2 million in the first five months of enrollment -- 75 percent of the administration's original goal for the period. It is not known how many people have paid the premiums needed to complete their enrollment.
How Close Enrollment Is to Targets Set by the Obama Administration
Enrollment in each state, from Oct. 1 to March 1 (Source: Department of Health and Human Services)
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The New York Times
April 30, 2015 Thursday
The New York Times on the Web
Last Chance to Sign Up Under Affordable Care Act Is Thursday
BYLINE: By ANN CARRNS.
Email: yourmoneyadviser@nytimes.com
SECTION: Section ; Column 0; Your Money; YOUR MONEY ADVISER; Pg.
LENGTH: 687 words
Consumers still have one more ''last chance'' to sign up for health insurance this year under the Affordable Care Act and avoid paying penalties for failing to have coverage.
But time is short. The new deadline is Thursday, April 30.
The official end of the second open enrollment period for coverage under the Affordable Care Act was Feb. 15. But the federal government announced a special enrollment period that extended the deadline until April 30 because many people didn't get the message that they would have to pay a penalty for failure to get coverage until after the Feb. 15 deadline. The reality hit home only when they filed their 2014 income taxes, which asked about health coverage and assessed the penalty for the first time.
So if you owed a penalty for lack of coverage last year, and you haven't yet signed up for a health plan, you can sign up through Thursday in most states. (You'll just need to attest that you didn't understand the requirement to have coverage.) The special option is available through Healthcare.gov, the federal marketplace, and through most state-run marketplaces. There are a few exceptions -- Colorado, Idaho and Massachusetts didn't offer extended tax-time deadlines, according to Enroll America -- and deadlines vary, so its best to check with the marketplace in your state.
The federal Centers for Medicare & Medicaid Services, which oversees the federal exchange, said that as of April 13, about 68,000 people had signed up under the tax-filing extension.
In California, about 33,000 people who signed up for coverage through the Covered California marketplace since February indicated they had been unaware of the penalty for being uninsured, the exchange reported this week. James Scullary, a spokesman for Covered California, noted that the penalty in effect doubles in 2015, ''and that could be a big bill for many consumers.''
If you didn't have coverage last year but you already signed up for insurance for 2015, you can't use the extension to switch plans, said Karen Pollitz, a health policy expert with the Kaiser Family Foundation. But if you haven't signed up yet, it's wise to take a look at the available options, she said, because the penalties for not having coverage are getting stiffer. The penalties are based on a formula that takes into account family size and income.
For instance, in 2014, the penalty for a single person was a minimum of $95, or 1 percent of income (income over a threshold of about $10,000 is used to calculate the penalty), whichever is larger. For someone making $40,000, that means a penalty of about $300.
For 2015, the penalty, based on the same salary, increases to at least $325 per person or 2 percent of income, totaling about $600.
(The penalty is capped, based on the average cost of a ''bronze'' level insurance plan -- about $2,400 for a single person for 2014.)
Cathy Kaufmann, enrollment program director for Families USA, an advocacy group, suggested that consumers try an online tool created by the Tax Policy Center to estimate their penalty.
If you want to sign up, however, you'll need to act quickly, though, because ''the door is closing,'' Ms. Pollitz said.
After Thursday, you must wait until the next open enrollment period this fall, unless you have a change in circumstances -- like losing your health coverage because of the loss of a job, getting married or having a baby, or moving to a state that doesn't offer your plan.
Here are some questions about the coverage and the special enrollment period:
â- If I sign up by April 30, will I avoid a penalty for 2015?
You'll still owe a penalty at tax time next year, for each month of this year that you lacked coverage, but it will be smaller. (The penalty is prorated; you'll owe one-twelfth of the penalty for each month you lacked coverage).
â- If I sign up by April 30, when will my coverage begin?
Coverage will take effect on June 1. To have coverage begin on May 1, you would have had to sign up by April 15.
â- When is the next open enrollment period?
The next open enrollment period begins Nov. 1, 2015, and ends Jan. 31, 2016.
URL: http://www.nytimes.com/2015/04/30/your-money/last-chance-to-sign-up-under-affordable-care-act-is-thursday.html
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December 29, 2014 Monday
Today in Politics
BYLINE: THE NEW YORK TIMES
SECTION: US; politics
LENGTH: 1529 words
HIGHLIGHT: Mr. Obama is halfway through his year-end trip to Hawaii. While he has kept a low profile, he’s been fairly busy.
Playing the Numbers Game With the Obamas' Christmas Vacation
Good morning on the last Monday of the year from Washington, where federal officials are awaiting calls for assistance involving AirAsia Flight 8501 , and former Gov. Jeb Bush of Florida, fresh off his announcement that he is exploring a presidential campaign, has a big lead in a new poll over other potential Republican contenders. We also start wrapping up the year by tallying statistics from President Obama's Hawaiian vacation and looking at the Twitter champions in Congress.
Mr. Obama is halfway through his year-end trip to Hawaii. While he has kept a low profile, he's been fairly busy. Here's a breakdown:
9 - Number of days the president has been in Hawaii.
6 - Number of times he has played golf.
7 - Number of golf partners. (His childhood friends Mike Ramos, Greg Orme and Bobby Titcomb; the White House staff members Mike Brush and Joe Paulsen; Prime Minister Najib Razak of Malaysia; the lawyer Preston Heard.)
2 - Number of putts Mr. Obama missed on the 18th green on Wednesday when reporters were allowed to see him finish a round with Mr. Razak.
2 - Number of putts the Malaysian prime minister missed on the 18th green.
1 - Number of times the president has bowled with friends when it was too rainy to golf.
4 - Number of times he has worked out at a local military base.
4 - Number of Obama family beach trips.
1 - Number of first family hikes.
2 - Number of times the White House spokesman has announced that Mr. Obama was briefed on breaking news events (the New York City police shootings in one case, and the missing plane in Asia in the other).
2 - Number of police chiefs the president has called (William J. Bratton of New York and Charles H. Ramsey of Philadelphia).
1 - The number of times Mr. Obama has praised the former senator and presidential candidate Gary Hart. He thanked Mr. Hart, who was appointed as special envoy to Northern Ireland in October, "for his hard work in support of" this month's Stormont House Agreement, shoring up the power-sharing government in Northern Ireland
- Michael S. Schmidt
In Brief, It Was a Good Year for Congress on Twitter
For Congress, 2014 was a really productive year - on Twitter, at least. Nearly every current member of the House and Senate who has an account increased his or her follower count on the social media site, according to data tracked by The New York Times.
Representative Trey Gowdy, the South Carolina Republican, sawhis social media profile rise significantly in a year when he was elevated to the chairmanship of a select committee investigating the 2012 attack in Benghazi, Libya. His 192 percent increase in followers since the beginning of the year tops all lawmakers who have at least 1,000 followers.
Others who saw substantial increases includedRepresentative Steve Scalise, the Louisiana Republican who is the new House majority whip;Senator Elizabeth Warren, Democrat of Massachusetts; andRepresentative Ileana Ros-Lehtinen, the Florida Republican who gained a large number of followers after posting about antigovernment protests in Venezuela. (We tracked only official accounts, not personal ones, meaning that some lawmakers with popular personal accounts on Twitter, such asSenator Marco Rubio, Republican of Florida, weren't included.)
Perhaps the most unexpected Twitter growth came fromRepresentative John D. Dingell, the Michigan Democrat and dean of the House who is retiring after 59 years in Congress. Like many lawmakers, he relies on staff members for day-to-day maintenance of his Internet presence. Mr. Dingell had 9,587 followers on Jan. 1 but had more than 23,000 by late December.
There were exceptions to the pattern of rapid gains. Some members' accounts experienced growth in the single digits, and those who leave Congress usually see at least some of their followers fall away. But for the most part, to be a member of Congress meant to gain followers.
- Derek Willis
Health Care Law to Be Tested Next Year in States and Supreme Court
The new year is shaping up as one of change and challenges for health care and the Affordable Care Act, although the open enrollment period has gone smoothly so far.
As state legislatures convene in coming weeks, many will again wrestle with the question of whether to expand Medicaid. Several Republican governors have expressed new interest, but they face skeptical legislators in their own party. Ohio and Arkansas, which expanded Medicaid this year, will refight those battles in 2015.
And for a third straight year, the Supreme Court will take up issues arising from the Affordable Care Act, among them a challenge to the subsidies that make coverage affordable. If critics prevail, millions of people in states that use the federal insurance exchange could lose their subsidies.
A ruling against the subsidies could create a political quandary for Republicans, whom Democrats would accuse of taking insurance from the needy. A more general question for 2015 is how Republicans will use their new control of Congress. Will they send President Obama a bill to repeal the Affordable Care Act? Will they pass legislation to chip away at it? Will the Obama administration negotiate with Republicans over such changes?
Or will Mr. Obama use his veto power to beat back all changes? And, finally, will Republican presidential candidates continue to insist on repeal?
In March and April, many taxpayers will, for the first time, face what the individual mandate means to them. On their tax returns, they will need to certify that they had insurance in 2014 or qualified for an exemption, or else they will have to pay a penalty, the "individual shared responsibility payment."
- Robert Pear
What We're Watching Today
Requests for American help from Indonesia, Malaysia or Singapore into the investigation of the AirAsia flight. The F.B.I., the National Transportation Safety Board, the Defense Department and the embassies in region are all on standby.
Developments in Afghanistan, a day after the United States ended its official combat mission there.
The situation in New York after the police commissioner, William J. Bratton, criticized officers for turning their backs as Mayor Bill de Blasio spoke during the funeral for Officer Rafael Ramos.
Republicans Turn a Fund-Raising Appeal Into a Fashion Statement
Republicans have been boasting of their new digital campaign toolbox, but as the 2016 presidential race kicks into gear, they have gone retro by using a vintage T-shirts as a fund-raising device.
The Republican National Committee is making a year-end push topeddle red and blue "Reagan/Bush '84" shirts for $27. The shirts are a "throwback to the days of strong, principled leadership in the White House," the committee says. (They are also a throwback to a very good year for Republican presidential politics: President Ronald Reagan carried 49 states.)
"Reagan/Bush '84" is also the all-time top seller at RetroPolitics.com, a nonpartisan site, followed by "Clinton/Gore '92" and its "Bull Moose" shirt, although "Mondale/Ferraro" and "Chisholm '72" showed strong sales this year, said Adam Samons, the site's founder.
This isn't the first time Republicans have opened their closet to raise money. The party's national committee also sells "limited edition" striped socks embroidered with an elephant and the signature of the elder President George Bush. They carry a $35 price tag.
And just before Christmas, Liz Cheney, the daughter of former Vice President Dick Cheney, took to Twitter to help the party sell Mr. Cheney cowboy hats for a minimum donation of $72 each. The Stetson-style hats are lined with the party's seal and engraved with his signature.
They seem to have been hot holiday sellers: the Republican National Committee says that because of "overwhelming demand," Mr. Cheney's hat is out of stock.
- Alan Rappeport
Our Favorites From Today's Times
President Obama discovers the challenges of trying to vacation with two teenage girls.
President George Bush, now 90, will remain in a Houston hospital for a few more days. He was admitted on Tuesday.
A new park leads to a gentrification debate in Washington.
Germany's trust in the Putin government has evaporated, and companies are rapidly pulling investments from Russia.
What We're Reading Elsewhere
A new poll from CNN finds that 23 percent of Republicans now support former Gov. Jeb Bush of Florida for the Republican presidential nomination. That's an increase of nine percentage points since the last survey, in November. Gov. Chris Christie of New Jersey is No. 2 at 13 percent, and the physician Ben Carson is in the third spot at 7 percent.
Campaign professionals may know more about your personal life than the N.S.A., Politico reports. (It asks, which politician has the "Viagra vote"?)
The New Yorker looks at the growing campaign for same-sex marriage in the Deep South, and the chances that it will succeed.
Peter Beinart says he "immersed myself in the vast literature" about Hillary Rodham Clinton and details in The National Journal what he calls the Unified Theory of Hillary: She's a top-notch planner but lousy at improvisation.
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July 27, 2012 Friday
Late Edition - Final
Hospitals Worry Over Cut In Fund For Uninsured
BYLINE: By NINA BERNSTEIN
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 1
LENGTH: 1391 words
President Obama's health care law is putting new strains on some of the nation's most hard-pressed hospitals, by cutting aid they use to pay for emergency care for illegal immigrants, which they have long been required to provide.
The federal government has been spending $20 billion annually to reimburse these hospitals -- most in poor urban and rural areas -- for treating more than their share of the uninsured, including illegal immigrants. The health care law will eventually cut that money in half, based on the premise that fewer people will lack insurance after the law takes effect.
But the estimated 11 million people now living illegally in the United States are not covered by the health care law. Its sponsors, seeking to sidestep the contentious debate over immigration, excluded them from the law's benefits.
As a result, so-called safety-net hospitals said the cuts would deal a severe blow to their finances.
The hospitals are coming under this pressure because many of their uninsured patients are illegal immigrants, and because their large pools of uninsured or poorly insured patients are not expected to be reduced significantly under the Affordable Care Act, even as federal aid shrinks.
The hospitals range from prominent public ones, like Bellevue Hospital Center in Manhattan, to neighborhood mainstays like Lutheran Medical Center in Brooklyn and Scripps Mercy Hospital in San Diego. They include small rural outposts like Othello Community Hospital in Washington State, which receives a steady flow of farmworkers who live in the country illegally.
No matter where they are, all hospitals are obliged under federal law to treat anyone who arrives at the emergency room, regardless of their immigration status.
''That's the 800-pound gorilla in the room, and not just in New York -- in Texas, in California, in Florida,'' Lutheran's chief executive, Wendy Z. Goldstein, said.
Lutheran Medical Center is in the Sunset Park neighborhood, where low-wage earning Chinese and Latino communities converge near an expressway. Hospitals are not allowed to record patients' immigration status, but Ms. Goldstein estimated that 20 percent of its patients were what she called ''the undocumented -- not only uninsured, but uninsurable.''
She said Congressional staff members acknowledged that the health care law would scale back the money that helps pay for emergency care for such patients, but were reluctant to tackle the issue.
''I was told in Washington that they understand that this is a problem, but immigration is just too hot to touch,'' she said.
The Affordable Care Act sets up state exchanges to reduce the cost of commercial health insurance, but people must prove citizenship or legal immigration status to take part. They must show similar documentation to apply for Medicaid benefits that are expanded under the law.
The act did call for increasing a little-known national network of 1,200 community health centers that provide primary care to the needy, regardless of their immigration status. But that plan, which could potentially steer more of the uninsured away from costly hospital care, was curtailed by Congressional budget cuts last year.
That leaves hospitals like Lutheran, which is nonprofit and has run a string of such primary care centers for 40 years, facing cuts at both ends.
On a recent weekday in Lutheran's emergency room, a Chinese mother of two stared sadly through the porthole of an isolation unit. The woman had active tuberculosis and needed surgery to drain fluid from one lung, said Josh Liu, a patient liaison.
The disease had been discovered during a checkup at one of Lutheran's primary care centers, where the sliding scale fee starts at $15. But the woman, an illegal immigrant, had no way to pay for the surgery.
Another patient, a gaunt 44-year-old man from Ecuador, had been in New York eight years, installing wood floors, one in Rockefeller Center. The man had been afraid to seek care because he feared deportation. Finally, the pain in his stomach was too much to bear.
Dr. Daniel J. Giaccio, leading the residents on their rounds, used the notches on the man's worn belt to underscore his diagnosis, severe B-12 deficiency anemia. The woodworker had lost 30 pounds in a month, and his hands and feet were numb. Reversing the damage could take months.
''This is a severe case of sensory loss,'' Dr. Giaccio said. ''Usually we pick it up much sooner.''
In some states, including New York, hospitals caring for illegal immigrants in life-threatening situations can seek payment case by case, from a program known as emergency Medicaid. But the program has many restrictions and will not make up for the cuts in the $20 billion pool, hospital executives said.
Groups that favor more restrictive immigration policies said they agreed that the cuts in the $20 billion fund were a burden. They said hospitals obviously had a duty to provide emergency care for everybody, including illegal immigrants.
''I kind of like living in a society where we don't let people die on the steps of the emergency room,'' said Mark Krikorian, the executive director of one such group, the Center for Immigration Studies in Washington.
But he said the answer lay in enforcing laws, so that illegal immigrants leave the country, not in extending health coverage.
''There is no ideal resolution to the problem, other than reducing the illegal population,'' he said. ''Incorporating illegal immigrants into health exchanges or directly taxpayer-funded health care legitimizes their presence.''
The Obama administration said the Affordable Care Act supported safety-net hospitals in other ways, pointing to measures that raise payments for primary care and give bonuses for improvements in quality.
''We are taking important steps to make health care more affordable and accessible for millions of Americans,'' Erin Shields Britt, a spokeswoman for the Department of Health and Human Services, said in an e-mail. ''Health reform isn't the place to fix our broken immigration system.''
With illegal immigration an issue in the presidential campaign, many politicians continue to steer clear of addressing the cuts.
Hospitals in New York State now receive $2.84 billion of the nation's $20 billion in so-called disproportionate share hospital payments.
Those payments start shrinking in 2014 under the law, and drop to $10 billion by 2019.
''It is a difficult time to really advocate around this issue, because there is so much antipathy against new immigrants,'' said Alan Aviles, president and chief executive of the Health and Hospitals Corporation.
The corporation runs New York City's public hospitals, which treated 480,000 uninsured patients last year, an estimated 40 percent of them illegal immigrants. The same worries haunt tiny Othello Community Hospital, in Washington state's rural Adams County, where it is the only hospital for miles around.
Last year, the state began requiring that participants in a basic health plan prove that they are citizens or legal residents.
As a consequence, 4,000 out of the 4,400 patients at the nearby primary care center, mostly immigrant farmworkers, lost their coverage, leaving Othello more financially vulnerable when those people need emergency care.
In Central California, Harry Foster, director of the Family HealthCare Network, another primary care center, called the Affordable Care Act ''a double-edged sword.''
Many low-wage earning citizens now lack employer-sponsored health insurance, and the health care industry is already competing for those who will gain coverage through the law. But no one is competing to treat those it leaves out, he said.
''We will receive more and more of those patients,'' he said, estimating that 40 percent of the area's residents were illegal immigrant farmworkers. ''But financially, we can't take on all the uninsured patients in the area, to the exclusion of all the others, and survive.''
In many ways Lutheran, a century-old hospital that refurbished a defunct factory to serve as its hub in the 1960s, has been a prototype of the law's new model: coordinating primary and preventive care to improve health outcomes while curbing costs. Yet it stands to lose $25 million from the cuts.
''This is an unintended consequence of the law,'' said Ms. Goldstein, the hospital's chief executive. ''But so far, nobody is doing anything to resolve it.''
URL: http://www.nytimes.com
LOAD-DATE: July 27, 2012
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GRAPHIC: PHOTO: Ivan Cortes, the director, speaks to patients at Park Ridge Family Health Center. It was started by Lutheran Medical Center in Sunset Park, Brooklyn, a hub for Latino and Chinese communities. (PHOTOGRAPH BY OZIER MUHAMMAD/THE NEW YORK TIMES) (A21)
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December 27, 2013 Friday
Late Edition - Final
Vista Workers Told Their U.S. Health Plan Fails Test
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 863 words
WASHINGTON -- The Obama administration has told Vista volunteers and other AmeriCorps workers that their government-provided health coverage does not measure up to the standards of the new health care law, and that they may be subject to financial penalties unless they obtain insurance elsewhere.
The notice has surprised and worried workers in AmeriCorps, the federal community service program that is often described as a domestic version of the Peace Corps.
Mary Strasser, the director of AmeriCorps' Vista program, described the changes in a bulletin to members on Dec. 16.
The coverage provided by the agency -- the AmeriCorps Health Care Benefits Plan -- ''does not satisfy the individual responsibility requirement of the Affordable Care Act,'' which takes effect on Jan. 1, Ms. Strasser said. Accordingly, she said, Vista members may be required to pay a tax penalty if they do not have other coverage and do not receive an exemption.
The impact on community service workers is another unanticipated consequence of the health care law, which is making coverage available at little or no cost to many uninsured people but disrupting coverage for others who already had it.
Abby Grosslein, a Vista member in New Orleans, said she thought it was strange that the health benefits provided by a federal agency did not meet the standards of a law adopted more than three and a half years ago. ''It would be nice if the government waived the penalty because we are a federally funded program,'' said Ms. Grosslein, 24, who is completing her third year of service with AmeriCorps. ''It's as if the right hand does not know what the left hand is doing.''
Moreover, she said: ''The Affordable Care Act has been on the books since 2010. Why are we hearing only now that our health plan is not compliant?''
Thousands of private employers and state and local government agencies have revamped their employee health plans to meet the law's requirements. But AmeriCorps says that its members are technically not employees, and that it does not have to provide them with the ''minimum essential coverage'' they need to comply with the individual mandate. ''There will be no changes to the AmeriCorps Health Care Benefits Plan,'' Ms. Strasser wrote.
Vista, or Volunteers in Service to America, was proposed by President John F. Kennedy in 1963, authorized by Congress in 1964 and folded into the AmeriCorps network of programs in 1993. Its members work in education, housing, jobs and social service programs.
President Obama -- a onetime community organizer -- is a big supporter, and he has called public service ''a central cause'' of his administration. In March, the White House said that ''AmeriCorps may be one of America's best assets,'' transforming communities every day.
Rick Christman of Lexington, Ky., a former member of the board of AmeriCorps' parent organization, the Corporation for National and Community Service, said no one expected that Vista workers would be subject to penalties because their health coverage was inadequate.
''It's unfortunate,'' Mr. Christman said.
Samantha Jo Warfield, a spokeswoman for the agency, said AmeriCorps members had several options: They can keep their current coverage; they can shop for coverage on the new insurance exchanges, including HealthCare.gov; and if they are under 26, they may be able to stay on their parents' insurance. In addition, some might be eligible for Medicaid, the federal-state program for low-income people, which is being expanded in about half the states.
AmeriCorps members say their existing coverage, which pays for doctors' services, hospital care and prescription drugs, meets most of their needs. However, according to the members' handbook, ''AmeriCorps does not provide benefits for any diagnosis that is considered a pre-existing condition,'' and the coverage for preventive care appears to be less than the law requires.
Sarah L. Sklaw, a 22-year-old Vista member from New York City, said: ''I really support the Affordable Care Act, and I don't want to be a naysayer. But it was surprising and frustrating to be told that our health coverage would not meet the law's standards, especially because the Corporation for National and Community Service told us at orientation in August that we did not need to worry about the issue.''
Other AmeriCorps members said they occasionally needed more extensive coverage to pay for treatment of pre-existing conditions or injuries requiring specialty care, and they noted that some members did dangerous work, such as fighting wildfires or building trails on steep mountains.
The AmeriCorps health plan is available at no cost to members of Vista and the National Civilian Community Corps, a residential program for young men and women, who help build homes, tutor children and provide disaster relief and other services.
Vista officials said that some members might qualify for exemptions from the individual mandate penalty because of their low incomes. Vista members receive allowances to cover the cost of food, housing and other basic necessities. But the amounts are low because members are expected to live at approximately the same economic level as those they serve.
URL: http://www.nytimes.com/2013/12/27/us/vista-workers-told-their-us-health-plan-fails-test.html
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GRAPHIC: PHOTO: ''It's as if the right hand does not know what the left hand is doing,'' said Abby Grosslein, a Vista volunteer in New Orleans. (PHOTOGRAPH BY CHERYL GERBER FOR THE NEW YORK TIMES)
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August 20, 2012 Monday
Aetna Agrees to Buy Coventry in $5.7 Billion Deal
BYLINE: MICHAEL J. DE LA MERCED
SECTION: BUSINESS
LENGTH: 423 words
HIGHLIGHT: The acquisition, which gives Aetna a larger share of Medicare and Medicaid, would be the biggest in the managed health care industry since the Affordable Care Act was signed into law in 2010.
6:37 p.m. | Updated
Aetna announced on Monday that it would buy Coventry Health Care for about $5.7 billion in cash and stock, a move Aetna said would help it expand further into government-backed programs like Medicaid and Medicare.
It is the latest deal in an industry that has been spurred to seek consolidation in part because of the Obama administration's sweeping expansion of health care coverage.
Last month, WellPoint agreed to buy Amerigroup for about $4.9 billion, in a deal that increased WellPoint's presence in the markets for Medicare, for older patients, and Medicaid, for low-income patients. DaVita, Cigna and the private equity firms BC Partners and Silver Lake have also struck multibillion-dollar deals.
But Aetna's acquisition would be the biggest in the managed health care industry since the Affordable Care Act was signed into law in 2010. Under the terms of the deal, Aetna, based in Hartford, will pay $27.30 in cash and 0.3885 of a share for each of Coventry's shares. At Friday's prices, that amounts to $42.08, a 20 percent premium over Coventry's closing price last week.
"Integrating Coventry into Aetna will complement our strategy to expand our core insurance business, increase our presence in the fast-growing government sector and expand our relationships with providers in local geographies," Aetna's chief executive, Mark T. Bertolini, said in a statement.
Aetna's shares were up 5.6 percent, to $40.18. Shares in Coventry climbed to $42.04.
Coventry, based in Bethesda, Md., offers a variety of insurance services, including government-financed programs. It earned $543.1 million last year on revenue of $12.2 billion, and its shares rose 17.5 percent in the 12 months before the deal was announced.
Aetna said the deal was expected to close by the middle of next year, and would lead to around $400 million of annual cost savings by 2015.
Aetna's move was widely praised. Analysts at JPMorgan Chase wrote in a research note on Monday that Coventry would enhance the company's presence in markets like Florida, Kentucky and western Pennsylvania.
They added, however: "While certainly enhancing, we don't see this as a game changer in terms of government focused capabilities for Aetna going forward."
Goldman Sachs, UBS and the law firms Davis Polk & Wardwell and Jones Day advised Aetna on the deal, while Greenhill & Company and the law firms Wachtell, Lipton, Rosen & Katz; Bass, Berry & Sims; and Crowell & Moring advised Coventry.
Aetna Shares Rise as Investors Applaud Coventry Deal
Aetna to Buy Genworth Unit
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January 18, 2017 Wednesday 00:00 EST
Chelsea Manning, Tom Price, Nigeria: Your Wednesday Briefing
BYLINE: CHRIS STANFORD and SEAN ALFANO
SECTION: BRIEFING
LENGTH: 1087 words
HIGHLIGHT: Here's what you need to know to start your day.
(Want to get this briefing by email? Here's the sign-up.)
Good morning.
Here's what you need to know:
Chelsea Manning to be released early.
President Obama commuted most of the 35-year sentence of Chelsea Manning, the Army intelligence analyst convicted of providing classified information to WikiLeaks in 2010 that revealed U.S. military and diplomatic activities.
Ms. Manning, a transgender woman who has served nearly seven years in a men's prison, wrote about her experience in a letter to The Times. She is to be freed in May.
Mr. Obama also pardoned James E. Cartwright, a retired Marine Corps general who lied to the F.B.I. about his discussions with reporters on Iran's nuclear program.
(The former N.S.A. contracter EdwardJ.Snowden was not on the list.)
Cabinet confirmation hearings continue.
Representative Tom Price of Georgia, the nominee for health and human services secretary, may face the toughest scrutiny of any cabinet choice so far when he appears before a Senate committee today. He is a vocal critic of the Affordable Care Act and a proponent of overhauling Medicare.
Scott Pruitt, President-elect Donald J. Trump's choice to lead the Environmental Protection Agency, will also face questions, as will Wilbur L. Ross, the commerce secretary pick.
On Tuesday, Betsy DeVos defended her work steering tax dollars from traditional public schools. Her confirmation hearing to be education secretary quickly became a partisan debate over school spending.
The cost of repealing Obamacare.
Eighteen million people could lose their insurance within a year and individual premiums would shoot up if Congress repealed major provisions of the Affordable Care Act while leaving other parts in place, a nonpartisan report has found.
Hunting militants, hitting refugees.
A Nigerian fighter jet searching on Tuesday for members of Boko Haram accidentally bombed a camp for people who had fled the militants, killing dozens of displaced people and at least six humanitarian workers.
Americans and gender equality.
A new poll has found that 82 percent of women in the U.S. believe that sexism is a problem today, and that men underestimate the sexism felt by the women in their lives.
Milestone for the planet.
Scientists reported today that Earth reached its highest temperature on record in 2016.
It means that for the first time in the modern era of global warming data, temperatures have broken the previous mark three years in a row.
Business
President Xi Jinping of China, speaking at the World Economic Forum in Davos, Switzerland, criticized protectionism while implicitly rebuking Mr. Trump.
The Chinese leader's economic adviser, an American-educated technocrat, is pushing for economic liberalization, but his agenda could be hurt by fears of a trade war.
Mark Zuckerberg, the chief executive of Facebook, appeared in federal court in Dallas on Tuesday to testify in an intellectual property case involving Oculus VR, a company he bought for more than $2 billion.
The trial offered a window into Mr. Zuckerberg's views of the virtual reality technology: "I don't think that good virtual reality is fully there yet," he said.
Corporate governance, which includes deciding which way to vote on the directors of a company board, is gaining importance in the U.S.
The field has also drawn attention because women hold the top governance positions at many of the biggest mutual funds and pension funds.
U.S. stocks were down on Tuesday. Here's a snapshot of global markets.
Noteworthy
Chaos in the Philippines.
President Rodrigo Duterte has unleashed an antidrug campaign that has killed thousands of people since June. Our latest 360 video portrays a grim reality in Manila.
What President Obama read in office.
Mr. Obama spoke to us about the indispensable role books played during his time at the White House and throughout his life. The apocalyptic sci-fi epic "The Three-Body Problem" and "The Underground Railroad," about the horrors of slavery, are among the books he read in recent years.
Here's a transcript of the interview.
The president also said that he likes to read the mail after dinner. He credits the letters with keeping him from becoming "cynical."
Reluctant "hometown hero."
That term makes the chef Vivian Howard uncomfortable, but to many in Kinston, N.C., she has helped put the hard-hit town on the map with her restaurant and popular TV show.
"Saving a town was not what I was trying to do," she said. "I'm just a storyteller. A storyteller who cooks."
Smarter Living: Morning Edition
(In this new section, we'll help you start your day right.)
Maybe you shouldn't skip your workout this morning - it just might help your brain grow stronger.
Here's a guide to help you teach young people about philanthropy, and to offer them the tools to give.
Recipe of the day: For a simple side dish, try braised greens spiced with red pepper flakes.
Back Story
The Oval Office is often used as shorthand for the U.S. presidency, but fewer than half of American presidents have worked there.
During President Theodore Roosevelt's administration (1901-9), the West Wing was added to the White House to hold the executive branch's growing staff. He had a rectangular office in the addition; it's now called the Roosevelt Room.
Earlier leaders had worked in the residence, mostly in what is now known as the Lincoln Bedroom. Roosevelt's successor, William H. Taft, had the Oval Office built and was its first occupant.
The design wasn't novel.
George Washington had oval rooms in Philadelphia in 1791, allowing him to seat guests around him. It mimics an English court tradition called the levée.
There was a precursor in the White House, too. The Blue Room, used for diplomatic receptions, is rounded. And in the family quarters, there's a Yellow Oval Room.
On Christmas Eve of 1929, the Oval Office was badly damaged in a fire. President Franklin D. Roosevelt had it renovated, moving it closer to the residence so that the "commute" is under a minute.
Presidents can redecorate, but there are limits. One is that the presidential seal must remain on the ceiling.
And there's another tradition: The departing president leaves a letter on the desk for his successor.
Adeel Hassan contributed reporting.
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The New York Times
July 30, 2014 Wednesday
The New York Times on the Web
Introducing the National Soda Tax
BYLINE: By MARK BITTMAN
SECTION: Section ; Column 0; Editorial Desk; CONTRIBUTING OP-ED WRITER; Pg.
LENGTH: 916 words
Get this: Rosa DeLauro, the brave and beloved 12-term congresswoman from New Haven, will be introducing a bill in the House of Representatives Wednesday that would require a national tax on sugar-sweetened beverages.
And it's about time. You know the big picture, even if you've forgotten the details, so I'm going to spare you the stats about obesity and diabetes that have been reiterated here and elsewhere ad infinitum. (If you want a refresher course, see this.) Suffice it to say that sugar-sweetened beverages are linked to obesity and diabetes, and that some form of control is needed. Many sugar-sweetened beverages contain more sugar per bottle than the American Heart Association's recommended daily limit and the Department of Agriculture's guidelines for sugar. (The Food and Drug Administration has not set standards for sugar consumption.)
The Obama administration made a tiny bit of noise about a soda tax back in 2009, but quickly backed off and has been silent on the subject since. For the last few years, there have been numerous attempts to get a significant (I'd call 10 percent of the price meaningful) tax on soda and other sugary drinks in a variety of cities and states. Berkeley, San Francisco and Illinois all have current initiatives, and, predicts Randy Shaw of the online daily BeyondChron, ''Berkeley's soda tax will pass.''
That'll be forceful, because a well-crafted soda tax is likely to work to reduce consumption of sugar-sweetened beverages, and therefore obesity, and therefore diabetes, and therefore health care costs, and to raise money for health education about the dangers of overconsumption of sugar.
But a national tax would be much tidier. Just eight months after it took effect, Mexico's soda tax is starting to show positive results -- consumption is down, at least -- and we could expect a similar performance from DeLauro's proposed bill. The SWEET Act (as she's calling it) would amend the I.R.S. code and charge a penny per teaspoon of sugar, high-fructose corn syrup or other caloric sweeteners -- ''to be paid by the manufacturer, producer or importer of such products.'' This would mean roughly a dime per can of soda, closer to 20 cents for a 20-ounce bottle or most medium-size soft drinks at restaurants. (Remember 6.5-ounce Cokes? The 20-ounce standard in part explains the obesity crisis.)
And the tax revenue would go to the Prevention and Public Health Fund established by the Affordable Care Act. Just how it would be used can't be predicted, but DeLauro suggests a variety of smart measures, including subsidies for fruits and vegetables in schools and for SNAP (food stamp) recipients and anti-soda marketing campaigns.
By this point you may be thinking that both DeLauro and I are bats, because it almost goes without saying that this bill, in this Congress, has as much chance of passing as real gun control, which is to say precisely none. But corny as it may sound, these things take time, and you have to start somewhere: The first national health care act was proposed in 1939, and the modern history of anti-tobacco legislation began in the 1960s. Both are now powerful realities.
''I'm not a Pollyanna,'' DeLauro said to me earlier this week, and she thinks it's time: ''I've been looking at this issue for a while, and I wanted to get it right. We are in the midst of a dual epidemic of obesity and diabetes, we need to do something about it, and we can't rely on industry to deal with this voluntarily.''
That's for sure; if there were an affordable and harmless sugar substitute that met with widespread public approval, the industry would happily use it, but barring that they're going to sell all the sugar-sweetened beverages they can persuade consumers to buy.
Which is why we need soda taxes, and why they're precisely the kinds of public health measures the federal government should be actively pursuing. States' rights are fine for some things, but why should the people of Illinois, for example, be measurably healthier than the people of neighboring Wisconsin, which is precisely what will happen a number of years from now if Illinois were to pass a soda tax?
DeLauro is the right person for this. She has a history when it comes to noble and seemingly ill-fated gestures. For example, she introduced a bill requiring calorie counts on restaurant menus more than 10 years ago and was then regarded, she says, as ''the crazy aunt in the attic.'' Yet a provision for menu labeling was included in the Affordable Care Act. (Sadly, the F.D.A. and the administration are both heel-dragging on this.)
With coalition-building (the American Public Health Association and the Center for Science in the Public Interest, among others, are supporting the SWEET Act), education and continuing research and revelations about the damage wrought by high sugar consumption, we should see increased support for regulation of the marketing and sales of what's sometimes called ''liquid candy.''
But DeLauro deserves kudos for bringing this to the House floor now; it's a major health issue that should wait no longer. When a generation passes, and people look back and ask, ''What do we wish we had acted on more quickly?'' there are three answers that come to my mind instantly: economic inequality, climate change and diet. The first may never be remedied; the second is the great global challenge of our time. The third -- especially when it comes to limiting sugar consumption -- is, no pun intended, a piece of cake. Let's get it done.
URL: http://www.nytimes.com/2014/07/30/opinion/mark-bittman-introducing-the-national-soda-tax.html
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The New York Times
July 11, 2014 Friday
Late Edition - Final
Suit Against Obama to Focus on Health Law, Boehner Says
BYLINE: By JONATHAN WEISMAN
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 459 words
WASHINGTON -- Speaker John A. Boehner's lawsuit against President Obama will focus on changes to the health care law that Mr. Boehner says should have been left to Congress, according to a statement issued Thursday by the speaker's office.
By narrowly focusing the legal action on the Affordable Care Act, Mr. Boehner will sidestep the more politically problematic issue involving Mr. Obama's executive action offering work permits for some illegal immigrants who were brought to the United States as children.
Last month, Mr. Boehner announced his intention to seek legislation allowing the House to sue the president over his use of executive actions, a reflection of charges by congressional Republicans that the president has overreached his authority. On Thursday, Mr. Boehner said the lawsuit would specifically challenge the president's decision to delay imposing penalties on employers who do not offer health insurance to employees in compliance with the Affordable Care Act.
''The current president believes he has the power to make his own laws -- at times even boasting about it,'' Mr. Boehner said in his statement. ''He has said that if Congress won't make the laws he wants, he'll go ahead and make them himself, and in the case of the employer mandate in his health care law, that's exactly what he did.''
''If this president can get away with making his own laws, future presidents will have the ability to as well,'' the speaker added. ''The House has an obligation to stand up for the legislative branch, and the Constitution, and that is exactly what we will do.''
Representative Nancy Pelosi, the Democratic leader in the House, called the suit a ''legal boondoggle doomed to fail.''
''This lawsuit is just another distraction from House Republicans desperate to distract the American people from their own spectacular obstruction and dysfunction,'' Ms. Pelosi said in a statement.
Mr. Boehner sought to clarify that he was not challenging Mr. Obama's right to issue executive orders, only his right to change legislation without congressional approval. Republican leaders have carefully avoided challenging the president's 2012 executive order concerning young illegal immigrants, although until Thursday, Mr. Boehner had refused to rule out such a challenge.
''In 2013, the president changed the health care law without a vote of Congress, effectively creating his own law by literally waiving the employer mandate and the penalties for failing to comply with it,'' Mr. Boehner said. ''That's not the way our system of government was designed to work. No president should have the power to make laws on his or her own.''
The House Rules Committee has scheduled a hearing on Wednesday to consider the legislation that would authorize the lawsuit.
URL: http://www.nytimes.com/2014/07/11/us/politics/boehner-says-obama-lawsuit-will-focus-on-health-law.html
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June 28, 2012 Thursday
Ruling Brings Relief at a Virginia Clinic
BYLINE: SABRINA TAVERNISE
SECTION: US; politics
LENGTH: 650 words
HIGHLIGHT: At a clinic that treats the poor, patients welcome news of the Supreme Court ruling.
LEESBURG, Va. -- There were no shouts, no whoops of joy. But the fortunes of the patients at the Loudoun Community Health Center quietly changed on Thursday morning when the Supreme Court ruled to uphold the Affordable Care Act.
The patients -- including a limousine driver, a cake decorator, an owner of a cleaning business, a crafts store worker and a home health aide -- did not know it yet, but the fact that the law survived meant that most of them would have health insurance, something that none of them can now afford.
"I am so happy, I have goose bumps," said Priscilla Jacques, a 53-year-old unemployed administrative assistant who had just emerged from a patient's room when she was told the news. "Thank God. I am so happy. This is really good for everyone. It really is."
Health centers like the one here play a major role under the health care law, and they are expected to treat many of the more than 30 million Americans who will be newly insured under the law. Loudoun Community Health Center received financing under the Affordable Care Act to expand to 18 patient rooms from 8.
Such health centers often offer the only medical care available for uninsured Americans. One-quarter of low-income uninsured Americans get their medical care at a community health center, said Amy Simmons, a spokeswoman for the National Association of Community Health Centers.
The court "made the right ruling," said Samantha Nastick, 31, whose part-time jobs at a crafts store and an assisted-living home do not offer health care benefits. Her family is grappling with serious health problems: her older sister has multiple sclerosis, and a younger sister was born with spina bifida. A new set of rules that require health coverage comes as a relief. "I'm hoping the law will make it so that we can get that stuff fixed," she said.
Once a rural farming area, Loudoun County has exploded with development over the last few decades, and it is now one of the country's wealthiest counties. But the recession dealt a painful blow to workers here, and the number of patients the health center serves has more than quadrupled since it opened in 2007.
"We laughed, and we shouted with joy and hugged each other," Angela Laws, a 58-year-old owner of a cleaning service, said in describing how she and her fiancé reacted when the decision was announced. Ms. Laws lost her house and nearly lost her business during the recession, and she has not been able to afford insurance. "I'm so excited," she said.
But not everybody in the clinic's waiting room on Thursday liked the ruling.
"I can't even wrap my brain around this; it's really crazy," said Lisa Jederman, who said she burned through her savings to pay for cataract treatments after she lost her job as a construction manager during the recession. The law "takes away our freedom to choose," she said, but added that she was glad community health centers like the one in Leesburg - which treated her eyes at almost no cost - would receive more support under the law. "I wouldn't have made it without this place," she said.
Colena Hammond, 48, who works as a waitress and an event planner in Richmond, Va., and goes to the Fan Free Clinic, a health care center for low-income people there, said the law would help erase the shame of not having insurance.
"I'm not indigent - I have a house, I have a car, I eat," she said. "But because I can't afford health care I'm pushed into that category. I'm sitting there in the waiting room thinking, 'I can't believe this is what I'm reduced to.' "
Under the law, her monthly premium would be just under $100 a month, according to a subsidy calculator provided by the Kaiser Family Foundation, a sum she said shd would "gladly pay."
"It would be such a relief," she said. "Such a weight lifted off of me."
A previous version of this post incorrectly stated that one in four of the patients at community health centers are employed.
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The New York Times
June 16, 2016 Thursday
Late Edition - Final
Obamacare Premiums Are Rising, Not a Little
BYLINE: By REED ABELSON and MARGOT SANGER-KATZ
SECTION: Section B; Column 0; Business/Financial Desk; PUBLIC HEALTH; Pg. 1
LENGTH: 923 words
Get ready for big increases in premiums under the Affordable Care Act. A new analysis from the Kaiser Family Foundation examined the most popular individual plans under the new health care law in 14 major cities around the country and found that insurers were asking for increases in 2017 that are twice as big as this year's. There is wide variation, including some places where rates will go down, but the average requested increase is 10 percent.
While it will be months before insurers and regulators agree to final rates for the coming year, the Kaiser analysis confirms the signals we have seen from industry and government experts -- that consumers and the federal government are likely to see much higher prices in many markets. Clearly, insurers are struggling to figure out how much to charge so they can cover their costs but still attract customers.
As health care reporters, we've been debating exactly how worried one should be about the fate of the Affordable Care Act, known informally as Obamacare, in the face of steep rate increases next year.
Reed: Margot, you were definitely right to sound the alarm last month. While it's still early -- and we don't know what regulators are likely to do with the proposals they're getting -- the Kaiser analysis seems to me another sign that we're a long way from having a stable individual market. Kaiser was looking at major cities, after all, where there is supposed to be plenty of competition and the market is supposed to work the best. But in our hometowns, New York City and Washington, the proposed rate increases were among the highest -- 16 percent for each market!
Margot: Seriously! D.C. likes to brag about how it has the highest enrollment rate and the youngest, healthiest risk pool in the country. But it seems clear that even the insurers here are struggling. I think these higher rates should remind us that this new market has proved much harder for insurers to figure out than we might expect three years in.
I think the news in some rural areas could be even worse. Those are the places where there's far less competition among insurers and hospitals. Charles Gaba, a blogger who closely tracks enrollment and insurer filings, has published a weighted-average rate increase for the states with numbers, and that one is way higher than Kaiser -- 22 percent. There are reasons his methodology will produce higher numbers than Kaiser, but he's finding much bigger increases than he did last year using the same method.
Reed: The prices are also concerning, even if the federal government ends up paying most of the bill. In New York and Vermont, a cheap silver plan, before taking into account subsidies, could end up costing more than $400 a month, according to the Kaiser estimates. In about half of the cities, somebody has to pay at least $300. That's steep.
Margot: I feel obliged to jump in and say that most people aren't paying those sticker prices now and won't next year, either. The federal subsidies protect low-income folks from the brunt of the increases. But people earning higher incomes are definitely going to feel these prices.
Reed: The question I have is whether this is a one-time adjustment or whether we are likely to see these kinds of rate increases in future years. What do you think?
Margot: I don't see any signs that the market is spiraling out of control. I think the insurers just underpriced to start, because of some combination of bad estimates, unexpected regulatory changes and perhaps unwise loss-leader strategies. Assuming they have better numbers to work with now and a firmer sense of the regulatory landscape, it seems reasonable to think this might be a one-time market correction.
Still, the increases look so high. What's the pessimistic case here?
Reed: For the insurers, it's that this group of people is sicker and costlier to cover than they bargained for. Unless the companies figure out how to manage those costs and keep premiums stable, the people sitting on the sidelines -- individuals who haven't enrolled or even employers deciding whether to send workers to the exchange -- will do their best to stay out of the market. Even if there's no so-called death spiral, the law doesn't succeed in providing coverage to the tens of millions who remain uninsured.
Margot: Well, I think we definitely need to adjust our expectations of who these marketplaces are primarily for. But I think having this health insurance option that didn't exist before is still really welcoming for a lot of low-income people who used to slip between the cracks.
Reed: And here's where I may be at least somewhat optimistic. While I won't begin to predict what will happen in the coming elections, I think it's possible that lawmakers could become more pragmatic. In states like Alaska, where the law doesn't seem to be working, at least there's some conversation taking place about what to do.
Margot: Speaking of politics, these are the sort of scary increases that Republicans have been warning about for years. Yet it doesn't seem like killing Obamacare is Donald Trump's top policy priority. How do you think this is going to affect the election?
Reed: It's hard to know. Most people still get their insurance through an employer, and those rates are not going up by double digits, so I'm not sure the outrage will be so widespread. About this issue, at least.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
URL: http://www.nytimes.com/2016/06/16/upshot/yes-obamacare-premiums-are-going-up.html
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GRAPHIC: PHOTO: Even in urban areas, where competition was expected to be brisk and the risk pool relatively young and healthy, insurers appear to be struggling. In 14 major cities, insurers are asking for 2017 increases twice as big as 2016's. (PHOTOGRAPH BY WHITTEN SABBATINI FOR THE NEW YORK TIMES) (B7)
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The New York Times
January 10, 2017 Tuesday
Late Edition - Final
Health Lobby Quiet as Law Faces Repeal
BYLINE: By ROBERT PEAR; Thomas Kaplan and Emmarie Huetteman contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1632 words
WASHINGTON -- The speed of Republican efforts to repeal the Affordable Care Act has stunned health industry lobbyists, leaving representatives of insurance companies, hospitals, doctors and pharmaceutical makers in disarray and struggling for a response to a legislative quick strike that would upend much of the American health care system.
The Senate is expected to take the first step by Thursday morning, approving parliamentary language in a budget resolution that would fast-track a repeal bill that could not be filibustered in the Senate. House and Senate committees would have until Jan. 27 to report out repeal legislation. Health insurance and health care for millions of Americans are at risk.
But far from reflecting the magnitude of the moment, the most prominent message from lobbyists that lawmakers saw in their first week back at work was a narrowly focused advertisement from the U.S. Chamber of Commerce demanding the repeal of ''Obamacare taxes,'' especially an annual fee imposed on health insurance companies to help pay for the expansion of coverage under the health law.
''More than 20 million people could lose their health insurance, and states could lose billions of dollars in Medicaid money,'' said Kenneth E. Raske, the president of the Greater New York Hospital Association. But, he added, many health care executives ''don't want to get on the wrong side of the new administration or the Republican majority in Congress.''
Health care professionals are not totally silent, but industries that were integral to the creation of the Affordable Care Act in 2010 are keeping their voices down as Republicans rush to dismantle it. Some Republican lawmakers are openly fretting about their leaders' repeal strategy, saying they must develop an Affordable Care Act replacement before they repeal it. Five Republican senators proposed on Monday to extend the deadline for drafting repeal legislation by five weeks, until March 3. One of the five, Senator Bob Corker of Tennessee, said the extra time would allow Congress and the Trump administration to ''get the policy right'' as they try to arrange a smooth transition to a new system of health coverage.
But the naysayers are getting no cover from a major lobbying and advertisement blitz like the ones that blanketed the airwaves in 2009 and 2010.
To block the repeal effort, said Senator Richard J. Durbin of Illinois, the No. 2 Senate Democrat, ''we need two or three Republicans to join us.''
Doctors are telling Congress to proceed with caution, insisting that no one should lose coverage. The American College of Physicians, representing 148,000 specialists in internal medicine, has sent letters to senators urging them to ''vote no'' this week on the budget resolution.
Hospitals were expecting to receive tens of billions of dollars in additional revenue for treating people who were newly insured under the health law, and they are alarmed at the prospect that it may now be repealed. But, they say, if Congress goes ahead and rolls back the expansion of coverage, it must also restore tens of billions of dollars that the health law cut from Medicare payments to hospitals.
Top executives from state hospital associations will fly to Washington this week to develop their strategy. Many also plan to visit offices on Capitol Hill, where they will warn of the potential damage if Congress repeals the health law without guaranteeing similar coverage for those who would lose it.
A coalition of consumers and liberal advocacy groups is spending more than $2 million on television advertisements urging Congress to stop its attack on the law. The ads, by the Alliance for Healthcare Security, are aimed at a handful of Republican senators, including Lisa Murkowski of Alaska, Jeff Flake and John McCain of Arizona, Susan Collins of Maine, Dean Heller of Nevada, Lamar Alexander and Mr. Corker of Tennessee, and Shelley Moore Capito of West Virginia.
But by Washington standards, that is a pittance. Pharmaceutical Research and Manufacturers of America, an industry lobbying group, set aside $150 million in 2009 to support the law's passage.
Some lobbyists have tacitly accepted the likelihood that major provisions of the health law will be repealed, setting their sights instead on shaping its replacement. They fear that if they come out strongly in opposition to repealing the law, they will lose their seats at the table as congressional Republicans and the Trump administration negotiate a replacement.
For now, passage of the budget resolution this week looks likely. The real fight is expected to come two to three weeks from now, when two House committees and two Senate committees produce legislation to repeal the Affordable Care Act and must answer to Republicans who say a replacement measure must be ready at the same time.
At least a half-dozen Republican senators have expressed doubts about the Republican leadership strategy of using the budget resolution to fast-track legislation to repeal the law, with a delayed effective date to allow time to find a replacement in the future.
''Repeal and replacement should take place simultaneously,'' Mr. Corker said last week. Senator Tom Cotton of Arkansas said on MSNBC, ''It would not be the right path for us to repeal Obamacare without laying out a path forward.''
Members of the hard-right House Freedom Caucus are also pressing leaders to embrace a replacement bill before they eviscerate the existing law.
And that concern is not confined to Congress. Gov. John R. Kasich of Ohio, a Republican, has also warned Congress against repealing the law without a replacement. What, he has asked, will happen to the 700,000 people who have gained coverage under the expansion of Medicaid in Ohio?
Senator Rand Paul, Republican of Kentucky, said that he spoke on Friday with President-elect Donald J. Trump, and that Mr. Trump agreed a replacement measure must be ready.
''I think he consistently has said, and I think many people who look at this say, 'Gosh, you're going to repeal this huge, dramatic thing and not have a replacement on the same day?''' Mr. Paul said on Monday. ''I mean, doesn't make a lot of sense to do that.''
Many of the lobbyists who might have slowed the process appear flummoxed, in part because they were expecting Hillary Clinton to win the election.
Some companies, anxious about changes in health policy, said they were afraid to speak out because they feared that Mr. Trump would attack them on Twitter, as he has badgered Boeing, Ford, General Motors, Lockheed Martin and Toyota.
Marilyn B. Tavenner, the chief executive of the leading lobby for insurers, America's Health Insurance Plans, is in a particularly awkward position. As an Obama administration official from 2010 to 2015, she led work on the health law, issued rules to carry it out and often defended it on Capitol Hill. In December 2015, Speaker Paul D. Ryan of Wisconsin pointed to her as an example of how federal officials passed through a revolving door to work for companies they once regulated.
''If the insurance industry does not understand how Obamacare works, why not hire the person who ran it?'' Mr. Ryan said in a gibe at Ms. Tavenner that drew laughter from his audience at the Library of Congress.
Ms. Tavenner said the requirement for people to have insurance -- the individual mandate -- was likely to be eliminated. But, she said, to stabilize the market, Congress should maintain ''subsidies for low- and moderate-income individuals to purchase insurance and financial help for plans that enroll high-cost individuals, through at least Jan. 1, 2019.'' She is also asking Congress to kill the tax on insurers, which has already been suspended for 2017.
Kaiser Permanente, the managed care company that serves more than 10 million people, declined to comment specifically on Republican plans to repeal the Affordable Care Act. Instead, it offered a statement of general principles saying that people should have access to health care and that ''we must continue to accommodate those who have pre-existing conditions.''
George C. Halvorson, a former chief executive of Kaiser Permanente, said insurers were guarded in their comments because the current environment was ''extremely politicized.'' He predicted they have more to say when Congress turns to the task of devising a replacement for the law.
''You need to make your point when it will have optimal impact,'' Mr. Halvorson said.
Lobbyists for the Blue Cross and Blue Shield Association have been more active and outspoken.
They support changes to the health care law because, they say, premiums and deductibles are too high and commercial insurers have been dropping out of the public insurance marketplaces. One-third of counties in the United States have only one insurer offering coverage in the marketplace, they say, and in many cases, it is a Blue Cross plan.
But Blue Cross lobbyists expressed alarm that Congress or a federal court might eliminate the cost-sharing subsidies that the government pays insurers to reduce out-of-pocket costs for low-income people. Without these payments, Blue Cross wrote in a primer delivered to congressional offices, consumers will see ''significant premium increases in 2018, making coverage even more unaffordable for millions of working Americans.''
While defenders of the Affordable Care Act try to figure out a strategy, conservative groups are pressing hard for full repeal of the law as soon as possible. Among them are Heritage Action for America, an offshoot of the Heritage Foundation, and Freedom Partners, a conservative group backed by the billionaire brothers Charles G. and David H. Koch.
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URL: http://www.nytimes.com/2017/01/09/us/politics/affordable-care-act-health-care-lobby.html
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(Economix)
October 25, 2013 Friday
The Midterm Grade for HealthCare.gov
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1309 words
HIGHLIGHT: It’s extraordinary how the rollout of HealthCare.gov was bungled and how little control over it the president seemed to have, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
I was challenged by people who commented on my last post to opine on the troubled rollout of the federal HealthCare.gov, and I will oblige.
The best place to start is President Obama's remarks in the Rose Garden of the White House on Monday.
Shortly before the president's appearance, White House officials that the "president will directly address the technical problems with HealthCare.gov - troubles he and his team find unacceptable." But in that Rose Garden appearance, the president did not explain what the technical problems with HealthCare.gov were, though he did acknowledge their existence and stated "there is no excuse" for them.
He then promised that in a techno-surge he would recruit the best information technology talent in the country to come to the rescue and fix the problems. It made me wonder why the A-team, as the White House now calls it, was not enlisted in the first place.
President Obama taught constitutional law at the University of Chicago Law School. How would he have graded a student's performance on, say, a term paper or test that the professor viewed as "unacceptable," especially when there was "no excuse" for the paper's deficiencies?
One would hope that the grade would have been F, even under modern grade inflation. I certainly would affix that grade to such inexcusably deficient work.
But who exactly should be assigned the F for the troubled rollout of HealthCare.gov?
At the Rose Garden ceremony, President Obama noted, "There's no sugar coating it, the Web site has been too slow, people are getting stuck during the application process, and I think it's fair to say that nobody is more frustrated by that than I am."
That makes it sound as if the president was surprised and then angered by the poor performance of HealthCare.gov. Indeed, in a television interview Tuesday with Dr. Sanjay Gupta on CNN, the secretary of health and human services, Kathleen Sebelius, appears to suggest as much, even though HealthCare.gov is reported to have crashed days before the start on Oct. 1 when only 100 people tried to register simultaneously.
As someone who has lectured on corporate governance and served on corporate boards, I find Secretary Sebelius's statement astounding. Is this how the project was managed? They knew the Web site was not working and yet decided to go ahead with it anyway, without the president's personal O.K. for so strategic and risky a decision?
Once elected, a president becomes chief executive of a giant federal enterprise. Anyone familiar with corporate management would have thought that for as ambitious and technically a complex project as the initial rollout of HealthCare.gov - so important to many uninsured Americans and so politically important to the White House - the chief executive would have remained in very close touch with the management team overseeing the project and thus would have been briefed daily or at least weekly on the progress of the project and especially on any problems with it.
Woe to the members of the management team in a corporation if problems with a project are hidden from the chief executive when they become known, exposing the chief executive to embarrassing public relations surprises. Heads would roll. The board, however, would assign the blame for such problems not primarily to the management team and instead to the chief executive himself or herself. He hired and supervised the team.
From that perspective, the blame for the disastrous rollout of HealthCare.gov goes to its entire management team, to be sure, but primarily to the chief executive on top of that project. In my view, not only the proverbial buck stops on the chief executive's desk, but, for the management of this particular project, the grade of F goes there as well.
It is worth reminding readers, however, that grades on midterm papers or tests do not constitute the overall grade in a course. Students receiving an F on a midterm paper or test often end up with a respectable overall course grade, spurred on in part by that very failure.
Similarly, with enormous effort and, one hopes, constant future supervision by the chief executive, there is hope that the technical problems encountered so far can be fixed in time, with the celebrated A-team of software experts now on the scene.
Finally, it bears emphasizing that the ill-fated rollout of HealthCare.gov should not be taken as a commentary on the concept of health insurance exchanges in general, nor on the Affordable Care Act.
The idea to use means-tested public subsidies to assist low-income Americans to purchase competitively offered private health insurance sold through health-insurance exchanges has been popular among policy analysts and policy makers of both political parties since the 1970s. Any such exchange will have to have roughly the same kind of architecture and tasks as those required for HealthCare.gov, as is shown in the sketch below.
Particular versions of this general construct were built into the Clinton health plan in the 1990s and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Part D of Medicare). It was also part of the health reform plan proposed by Senator John McCain, Republican of Arizona, during the presidential campaign of 2008 and of the Patients' Choice Act proposed by Senator Tom Coburn, Republican of Oklahoma, in 2009.
Indeed, it has been the foundation of every health reform proposal in the United States other than the single-payer Medicare for All idea since the 1970s. And it would be the core of the defined contribution plan now being proposed by Representative Paul Ryan, Republican of Wisconsin, for the Medicare program.
Now, it may be argued that private electronic health insurance exchanges - for example, eHealthInsurance.com - have long been available to Americans in the market for individually purchased private health insurance, obviating the need for a new HealthCare.gov. That would imply an unfair comparison.
EHealthInsurance.com is a purely passive exchange that merely lists the policies and estimates of their premiums for sundry health insurers listing on the exchange. It does not grant subsidies toward the purchase of health insurance and establish eligibility for those subsidies, nor does it guarantee prices. It simply refers interested individuals to insurers to purchase policies, which are not community rated but actuarially priced. Such an exchange can be quite simple.
If one wants to couple means-tested federal or state government contributions toward private coverage - as the health-reform plans proposed by both parties do - then by necessity the insurance exchange must ping and interact with numerous other Web sites, each with its own software language of various vintages.
The sketch below illustrates that construct, but only for the most important linkages that must be pinged. HealthCare.gov probably has to ping still other sites. Such an exchange is incomparably more difficult to establish and prone to computer glitches than is, say, eHealthInsurance.com.
But several states did manage to establish on time such complex health insurance exchanges under the Affordable Care Act, with only minor rollout glitches of the sort one would expect. Somehow they managed.
With proper management and more energetic work earlier on, and untainted by the political desiderata reported to have affected the architecture of HealthCare.gov, that Web site's management team should have been able to achieve the same success. It did not, hence the midterm grade F.
Dealing With Drafting Errors in the Health Care Law
The Hurdles to Success for the Affordable Care Act
How to Gut Obamacare
Obamacare vs. Romneycare: The Labor Impact
The Path to Complexity on the Health Care Act
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December 5, 2014 Friday
Late Edition - Final
Officials Say Price Comparison Is Crucial to Choosing Health Plans
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 21
LENGTH: 721 words
WASHINGTON -- The Obama administration on Thursday said that millions of people with health insurance purchased in the new federal marketplace would need to switch to different health plans to avoid increases in premiums or reductions in the subsidies they received from the government.
In other words, officials said, consumers may need to find new health plans if they want to make sure their coverage under the Affordable Care Act is, indeed, affordable.
But, the officials emphasized, more health insurance plans will be on sale in the federal marketplace next year, and most consumers will be able to find health plans for less than $100 a month, with subsidies.
''More than seven in 10 of our customers can find lower prices by shopping,'' said Kevin J. Counihan, the chief executive of the federal insurance marketplace. ''Roughly eight in 10 of our customers can get coverage for less than $100 a month after tax credits.''
So far, it appears relatively few consumers have taken the advice offered by federal officials.
When the open enrollment period began on Nov. 15, about 6.7 million people already had coverage through exchanges created under the 2010 health care law. As of Nov. 28, only 6 percent of them had returned to the marketplace and renewed their coverage or selected different plans for 2015.
If people take no action by Dec. 15 to renew or replace policies purchased on the federal exchange, they will be automatically enrolled in the same plan or a similar plan, effective Jan. 1. Consumers have until Feb. 15 to change or make their selections for the rest of 2015.
In much of the country, Mr. Counihan said, consumers will see more choices and competition in the marketplace. ''Ninety percent of our customers now can choose from three or more insurers, up from 74 percent in 2014,'' he said.
Competition tends to reduce prices, but in many places, Mr. Counihan said, it has also reduced subsidies, which are tied to the price of a benchmark ''silver plan.'' On average, such plans pay about 70 percent of the cost of care for a typical consumer.
While consumers can usually save money by switching plans, they will often face higher premiums or lower subsidies if they remain in their current plans, federal officials said.
''For the vast majority of people, if they stay in the same plan, they will see rate increases in the single digits, to high single digits,'' said Andrew M. Slavitt, the No. 2 official at the Centers for Medicare and Medicaid Services.
Some consumers have complained about price increases for 2015. But Richard G. Frank, an assistant secretary of health and human services, said that premiums for the benchmark silver plan held stable, with an increase of only 2 percent on average in states using the federal exchange.
Mr. Frank said the price increases were ''far lower than they have been historically.'' In the past, he said, consumers buying insurance on their own regularly faced increases of 12 percent to 15 percent a year.
Prices vary greatly from state to state and even among counties in the same state. A report issued by the administration on Thursday showed that lower premiums often, but not always, correlated with more competition.
In New Hampshire, for example, where the average number of health plans increased to 38 per county in 2015, from 10 in 2014, the average premium for a 27-year-old in a benchmark silver plan declined by 14 percent, to $205 a month, from $237.
And in Mississippi, where the average number of plans rose to 27 per county, from 13 this year, the average premium for the benchmark plan fell 20 percent, to $249 from $311.
By contrast, in large parts of Alaska, where the number of health plans declined to 28, from 34, the premium for a benchmark silver plan for a family of four increased 28 percent, to $1,624 in 2015, from $1,265 this year.
And in Wyoming, the number of plans more than doubled, to an average of 40 per county, but premiums on the federal exchange are among the highest in the country. For a benchmark silver plan, the price will rise 5 percent for a family of four, to an average of nearly $1,300 a month, the administration reported.
Nearly two-thirds of people with marketplace coverage in the past year had silver plans. The administration said they could save nearly $500 a year by selecting a different silver plan for 2015.
URL: http://www.nytimes.com/2014/12/05/us/affordable-care-act-enrollments.html
LOAD-DATE: December 5, 2014
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January 23, 2017 Monday
Late Edition - Final
Proposed Cure for Health Act Could Harm Costliest Patients
BYLINE: By REED ABELSON
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1467 words
Joanne Fitzgerald was getting divorced and was stressed out. When stomach pain kicked in, she saw a doctor to have it checked out.
That was her mistake.
The doctor diagnosed a mild form of gastritis, an inflammation of the stomach lining, and recommended some over-the-counter medicine. But when the divorce became final, in 2008, she lost health coverage from her husband's employer, and insurer after insurer refused to cover her because of the condition. She was finally offered a policy that excluded coverage for anything related to her gastrointestinal tract.
''I thought I was being smart in going to the doctor and getting checked out,'' Ms. Fitzgerald, 55, who currently lives in Washington, D.C., said recently. ''Then I tried to go get insurance and everyone denied me.''
Her fortunes changed under the Affordable Care Act, the major health law signed by President Barack Obama that required insurers to cover pre-existing medical conditions. She was one of the millions of people who jumped at the opportunity and bought a policy available under the new law.
Now, after President Trump and the Republican-controlled Congress have vowed to repeal and replace the health law, one of the most vexing questions is whether people like Ms. Fitzgerald will be covered.
About 27 percent of people under 65 are thought to have some sort of pre-existing condition that will most likely leave them without individual insurance if the law is repealed, according to a recent study. The guarantee of coverage has already become a rallying cry for people who want to keep the law.
The issue ''is the third rail'' for the Republicans, said Michael Turpin, a longtime health industry executive.
Before the law, a fairly typical life event -- like a divorce or the loss of a job -- and a relatively minor medical condition could upend a person's health coverage options. Stories of sick people unable to get coverage when they needed it most were legion.
Mr. Trump insists he wants to keep the pre-existing requirement for insurers, and other top Republicans say people who want coverage should not be turned away. Details about how they will cover people with existing medical conditions have not yet emerged, but many lawmakers have started pushing an idea -- known as high-risk pools -- that left many people uncovered or with strict limits to their coverage in the past.
The challenge for lawmakers is this: How do you get insurers to cover people who will definitely need costly medical care -- and do so without making insurance too expensive for everyone?
The Affordable Care Act addresses that question by requiring everyone to get coverage or face a tax penalty. That mandate is meant to increase the number of healthy people who have insurance, distributing the costs of caring for those who are sick across a wider population. The thinking is that if enough healthy people sign up, the costs of sick people will be offset for insurers.
Top Republicans, though, say the system is not working and point to double-digit price increases for premiums.
''There is a better way to fix that problem without giving everybody else all these massive premium increases,'' the House speaker, Paul D. Ryan, said at a recent televised forum.
Finding a fix is far from simple. Before the law was passed, insurance companies evaluated the health of each person applying for coverage before offering a policy, and priced the plan to reflect the possible cost of care. The companies wanted to minimize the risk of losing money by paying for costly medical care for too many of their customers.
Often, insurers offered no options to people with pre-existing conditions, because they considered the potential costs to be too high. As a result, 35 states had high-risk pools, the program again on the lips of top lawmakers, including Mr. Ryan.
The high-risk programs offered a separate insurance pool for people with potentially expensive medical conditions. The idea is that by separating sick people from the majority of people who are healthy, insurers could offer cheaper rates to the healthy people. Insurers could charge higher prices to those with existing medical conditions, but they would also rely on other sources of funding, including from the government, to cover their costs.
The system worked for Dan Nassimbene and his wife, who had breast cancer but is in remission. They enrolled in Colorado's high-risk pool for three years. She paid about $375 a month for a plan that covered most of her treatments.
In 2014, though, the high-risk pool was closed, and Mr. Nassimbene bought a plan that met the requirements of the Affordable Care Act. The cheapest plan he could buy for himself and his wife cost around $900 a month and came with a family deductible of around $12,000, much higher than it was before. His income was too high for him to receive any government subsidies, which help about 80 percent of people buying such plans.
''I had coverage but no access,'' said Mr. Nassimbene, 55. He has since switched to a Christian health care sharing ministry, in which members cover one another's medical bills. It does not qualify as coverage under the law.
In many cases, the high-risk pools were overburdened financially, leaving many people without insurance or with tight restrictions on coverage. Insurers refused to cover the individuals who were likely to have the highest expenses, like those who had H.I.V. or serious kidney disease, and the pools lost money.
Many states had to turn applicants away -- in some states, only a small percentage of those who applied received coverage -- and the insurance was sharply limited to control spending.
In Washington, over 80 percent of the people referred to the state's high-risk pool never got health insurance, said Mike Kreidler, the state's insurance commissioner. In California, which relied on lawmakers to allocate money as part of the state budget, there was a waiting list, recalled Richard Figueroa, who was a senior administrator for the program.
The pool operated on a first-come-first-served basis, Mr. Figueroa said, without regard to people's income or the severity of their medical condition.
''There were people literally dying on the waiting list,'' he said.
In addition, most of the states offering coverage had caps on payments for medical care. Washington's annual maximum was $2 million, while California's limit was $75,000 a year. Under the Affordable Care Act, insurance plans cannot have such a limit.
In California, the program dwindled away until it served only 6,300 at the end of 2011.
Dennis Carr, for example, worked as an independent real estate agent when the financial markets crashed in 2008. He had savings, but he eventually had to drop his Blue Cross plan because his income had tailed off and he could not afford it. Mr. Carr, who is now 51, said his goal was to resume coverage as soon as he was financially secure.
When he reapplied to the same insurer a few months later, he was rejected -- and then rejected again by another insurer because of his asthma and a sinus condition.
''It was just a real, real slap,'' Mr. Carr said.
He was directed to California's high-risk pool but found the premiums too high. He moved to Mexico as a way to afford his medications. He now lives in Phoenix, where he has coverage through an employer.
''For all the thousands of people who self-selected out because they couldn't afford it, it broke our hearts on a daily basis,'' Mr. Figueroa, the California official, said.
For others, the coverage offered by the high-risk pools was too limited for them to receive the care they needed.
Beth Martinez, 40, who has multiple sclerosis, was forced to join Texas' high-risk pool when she and her husband moved to Austin. Only six visits to the doctor were covered, and she found she could not afford the annual M.R.I. recommended to monitor her disease because of her high deductible. At one point, she said, she went four years without an M.R.I.
She and her husband now live in California and are covered through private plans offered through that state's marketplace, which meet all the health law's requirements for pre-existing conditions. Because she can work only part time, she is eligible for federal subsidies, which bring the couple's costs to $70 a month. Ms. Martinez had paid $275 a month in the Texas pool to cover herself, and her husband was uninsured.
She now gets the M.R.I.s she needs under her plan, and her policy even pays for physical therapy, which allows her to put in longer hours at her job as a hairstylist and makeup artist.
That sort of quality coverage, Ms. Martinez said, is a big departure from what she had through the high-risk pool, adding that ''it was definitely some of the worst insurance I had in my life.''
URL: http://www.nytimes.com/2017/01/22/business/president-donald-trump-health-insurance-high-risk-pool.html
LOAD-DATE: January 23, 2017
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GRAPHIC: PHOTO: Joanne Fitzgerald was repeatedly rejected by health insurers before she was able to get coverage under the Affordable Care Act. (PHOTOGRAPH BY MATT ROTH FOR THE NEW YORK TIMES) (A17)
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April 5, 2014 Saturday
Late Edition - Final
Law Lifts Enrollment in Medicaid by Millions
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 787 words
WASHINGTON -- Enrollment in Medicaid has increased by three million people, to a total of 62 million, largely because of the Affordable Care Act, the Obama administration said Friday.
As expected, the increases have been much greater in states that expanded Medicaid eligibility.
''The increase in Medicaid enrollments across the country is encouraging, but more work is left to do,'' said Kathleen Sebelius, the secretary of health and human services, who is trying to persuade more states to expand the program.
The new figures compare February enrollment in Medicaid and the Children's Health Insurance Program with the average monthly enrollment from July to September 2013, just before the health insurance marketplaces opened.
About half of the states, including California and New York, have expanded Medicaid. In states where the expansion was in effect in February, enrollment increased by 8.3 percent, to a total of 35 million people. In states that have not expanded Medicaid, enrollment was up 1.6 percent.
It was not immediately possible to confirm the government data. But the federal figures are consistent with estimates by independent experts.
Medicaid expansion is one of the two main policies that President Obama and congressional Democrats chose in extending health care coverage to more Americans. The White House reported this week that 7.1 million people had signed up through the other channel: private health plans sold in new insurance marketplaces.
The government numbers do not include people who enrolled in Medicaid last month in response to a publicity campaign by Mr. Obama and other officials. The Affordable Care Act requires most Americans to carry insurance. People seeking coverage had help from a small army of insurance counselors.
Edwin C. Park, an analyst at the Center on Budget and Policy Priorities, a liberal research and advocacy group, said the federal Medicaid data did not distinguish between newly eligible beneficiaries and those who were previously eligible but not enrolled.
Enrollment was up even in some states that have not expanded Medicaid. In Florida, the number of people on Medicaid rose 8.2 percent, to 3.2 million. In Montana, it was up 6.9 percent, to 149,000.
States with the largest percentage increases included Oregon, West Virginia, Vermont and Colorado, all of which have expanded eligibility.
Officials said the new numbers were underestimates. Not all states have reported data for February. The figures are also preliminary; some people will later be found eligible for Medicaid by the government, with coverage retroactive to February.
Many people who applied to the federal insurance exchange appeared to be eligible for Medicaid. The federal government is supposed to transfer their files electronically to state Medicaid agencies, but has had difficulty doing so.
People can sign up for Medicaid at any time. The open enrollment period for buying private insurance through federal and state exchanges ended on Monday, but the deadline did not apply to Medicaid.
In addition, Ms. Sebelius noted, there is no deadline for states to expand the program.
The mere existence of current enrollment data is one of the most remarkable features of the new report. The Department of Health and Human Services typically takes two years or more to publish such data, frustrating researchers and policy analysts. The Affordable Care Act simplified application procedures and required states to upgrade Medicaid information systems so that the federal government can now collect the data more quickly.
The Congressional Budget Office says that as a result of the health care law, eight million people are likely to gain coverage this year under Medicaid and the Children's Health Insurance Program, increasing federal spending by $19 billion.
In states that expand eligibility, coverage is generally available to people under age 65 whose incomes are up to 138 percent of the federal poverty level (up to $16,100 for an individual and $32,900 for a family of four).
In some states, the number of people qualifying for Medicaid under the new law exceeds the number obtaining private insurance. This unexpected pattern troubles some Republicans.
''The administration seems particularly proud of the fact that Obamacare has added hundreds of thousands of Americans to Medicaid,'' said Senator John Cornyn of Texas, the chamber's No. 2 Republican. ''The problem is that Medicaid is a fundamentally broken program that is failing our neediest citizens.''
Enrolling in Medicaid is often easier than picking a private plan in an online exchange. The exchanges are new institutions, while state Medicaid agencies have decades of experience assessing eligibility and helping people enroll.
URL: http://www.nytimes.com/2014/04/05/us/politics/health-law-helps-increase-medicaid-rolls-by-3-million.html
LOAD-DATE: April 5, 2014
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GRAPHIC: CHARTS: More Medicaid Enrollment in States With Expanded Eligibility (Source: Department of Health and Human Services) (A12)
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(You're the Boss)
August 29, 2014 Friday
The N.F.I.B. Is Certifying Small-Business-Friendly Politicians
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 314 words
HIGHLIGHT: How closely do the National Federation of Independent Business’s priorities match yours? If you were certifying candidates as small-business friendly, which issues would you cite?
With the fall midterm elections approaching, the National Federation of Independent Business has released a measuring stick to rate congressional candidates on their fidelity to small businesses. While this is standard political advocacy, this year it goes under the novel banner of making candidates "small-business certified." But N.F.I.B.'s acid-test positions are hardly new.
In order to win small-business certification, candidates must pledge to support five Republican-sponsored bills in the House of Representatives. One would prohibit the Environmental Protection Agency from limiting greenhouse gas emissions from new coal or natural gas power plants. Another would amend the Constitution to require a balanced federal budget.
Three other bills are aimed at blunting the Affordable Care Act. One would repeal a tax on fully insured health insurance plans that helps fund the law, a tax that the N.F.I.B. argues will largely affect small-group plans. Another would raise the threshold for when a full-time worker must be offered company health insurance to 40 hours a week from 30 hours a week. The last bill would waive the employer mandate penalty if the government found that the health law made premiums more expensive for small businesses or caused them to reduce employment.
One noteworthy aspect of this agenda is that most of these measures remedy concerns that affect small businesses only indirectly. Even the health insurance tax is not, strictly speaking, a tax on small-business owners; it's a tax on insurance carriers that sell policies to small businesses. And to some, the connections between small businesses and utility emissions or the federal budget may seem tenuous.
If you are a small-business owner, please tell us: How closely do the N.F.I.B.'s priorities match yours? If you were certifying candidates as small-business friendly, which issues would you cite?
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(The New Old Age)
November 1, 2013 Friday
Dental Coverage on the Insurance Exchanges
BYLINE: SUSAN JAFFE
SECTION: HEALTH
LENGTH: 653 words
HIGHLIGHT: Some adults with Medicare may be able to buy dental coverage on the new insurance exchanges, but there are many drawbacks.
Older adults and their caregivers have complained for years that Medicare, which now covers 52 million Americans, does not provide dental benefits.
"It's a huge problem," said Barbi Jo Stim, a geriatric care manager at Jewish Family and Children's Services of the East Bay, a social service agency in Berkeley, Calif. "If older adults can't afford the dental work they need, they can't chew, they don't get the nutrition they need and that can affect their overall health."
For some adults with Medicare, the online insurance exchanges created by the Affordable Care Act may offer an alternative (assuming they become functional in the near future). True, the vast majority should not purchase health insurance on the exchanges. But unless they are enrolled in a private Medicare Advantage managed care plan that already includes dental benefits, Medicare beneficiaries are legally permitted to purchase dental plans on the exchanges.
"There is nothing in the Affordable Care Act that prohibits the sale to Medicare beneficiaries of standalone dental plans on the exchanges," said Leslie Fried, policy and programs director at the National Council on Aging in Washington, D.C.
Still, there are drawbacks. The standalone dental plans for adults can set annual dollar limits on coverage and don't have to comply with caps on out-of-pocket spending mandated by the A.C.A. for health plans. Insurance premium subsidies and assistance with out-of-pocket expenses are not available. And in some states, exchange dental plans can reject adult applicants because of pre-existing conditions.
The choices vary dramatically by state.
In the 36 states where the federal government is running exchanges, dental coverage is available only to those who also buy health coverage, said an official at the Centers for Medicare and Medicaid Services, the agency operating those exchanges. That means someone with Medicare cannot purchase standalone dental coverage, even though federal law allows the sale of these policies to Medicare beneficiaries.
The Maryland Health Connection offers 20 dental-only policies that seniors who have Medicare can buy, said Danielle Davis, communications director for the Maryland Health Benefit Exchange. But Covered California, that state's insurance exchange, offers stand-alone dental plans that cover only children. Adult coverage may be added next year.
New York officials announced in August that the state's exchange would sell 10 dental plans, but now say the policies are wrapped into health plans and are not offered à la carte.
"The need for separate adult dental policies was not raised during public forums about New York's exchange benefits package," said Lisa Sbrana, counsel to the N.Y. State of Health exchange. "We would definitely consider it if New Yorkers expressed an interest in it."
In the District of Columbia, seniors in Medicare can choose from five stand-alone dental plans in DCHealthLink, said Mila Kofman, executive director of the District of Columbia Health Exchange Authority, "but all also include coverage for children."
These plans cannot turn away applicants because of pre-existing conditions, but dental plans sold outside the exchange can, said assistant insurance commissioner Philip Barlow. That's not true everywhere, however.
So what's the bottom line?
Medicare beneficiaries may be able buy standalone dental plans on certain state exchanges; however, they may not be much better than those available outside the exchanges. Many standalone exchange dental plans include coverage for children, which seniors don't need, and that can increase the premiums. If your state exchange does sell dental-only plans and you have Medicare, don't expect financial assistance.
Q & A: Medicare and the Insurance Exchanges
Two Kinds of Hospital Patients: Admitted, and Not
Health Care on Credit
Faster Assistance for Medicare Patients
A Check on Premature Hospital Discharges
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The New York Times
February 21, 2014 Friday
Late Edition - Final
Public Sector Capping Part-Time Hours to Skirt Health Care Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1219 words
WASHINGTON -- Cities, counties, public schools and community colleges around the country have limited or reduced the work hours of part-time employees to avoid having to provide them with health insurance under the Affordable Care Act, state and local officials say.
The cuts to public sector employment, which has failed to rebound since the recession, could serve as a powerful political weapon for Republican critics of the health care law, who claim that it is creating a drain on the economy.
President Obama has twice delayed enforcement of the health care law's employer mandate, which would subject larger employers to tax penalties if they do not offer insurance coverage to employees who work at least 30 hours a week, on average. But many public employers have already adopted policies, laws or regulations to make sure workers stay under that threshold.
Even after the administration said this month that it would ease coverage requirements for larger employers, public employers generally said they were keeping the restrictions on work hours because their obligation to provide health insurance, starting in 2015, would be based on hours worked by employees this year. Among those whose hours have been restricted in recent months are police dispatchers, prison guards, substitute teachers, bus drivers, athletic coaches, school custodians, cafeteria workers and part-time professors.
Mark D. Benigni, the superintendent of schools in Meriden, Conn., and a board member of the American Association of School Administrators, said in an interview that the new health care law was having ''unintended consequences for school systems across the nation.''
In Connecticut, as in many states, significant numbers of part-time school employees work more than 30 hours a week and do not receive health benefits. ''Are we supposed to lay off full-time teachers so that we can provide insurance coverage to part-time employees?'' Mr. Benigni asked. ''If I had to cut five reading teachers to pay for benefits for substitute teachers, I'm not sure that would be best for our students.''
In Medina, Ohio, about 30 miles south of Cleveland, Mayor Dennis Hanwell said the city had lowered the limit for part-time employees to 29 hours a week, from 35. Workers' wages were reduced accordingly, he said.
''Our choice was to cut the hours or give them health care, and we could not afford the latter,'' Mr. Hanwell, a Republican, said. The city's 120 part-time employees include office clerks, sanitation workers, park inspectors and police dispatchers.
Mr. Hanwell said that new rules issued by the Internal Revenue Service this month did not address the city's fundamental concerns about the cost of providing health insurance.
Lawrence County, in western Pennsylvania, reduced the limit for part-time employees to 28 hours a week, from 32. Dan Vogler, the Republican chairman of the county Board of Commissioners, said the cuts affected prison guards and emergency service personnel at the county's 911 call center.
In Virginia, part-time state employees are generally not allowed to work more than 29 hours a week on average over a 12-month period. Thousands of part-time state employees had been working more than that, according to the state personnel agency.
Virginia officials said they could not extend coverage to part-time wage workers because of the expense. Health benefits cost the state an average of more than $11,000 a year per employee.
For months, Obama administration officials have played down reports that employers were limiting workers' hours. But in a report this month, the Congressional Budget Office said the Affordable Care Act could lead to a reduction in the number of hours worked, relative to what would otherwise occur.
Jason Furman, the chairman of the president's Council of Economic Advisers, reaffirmed the White House view that the law was ''good for wages and incomes and for the economy over all.''
Since Mr. Obama signed the health law in March 2010, the private sector has added more than eight million jobs. But in the public sector, the picture is different.
Government employment at the federal, state and local levels is lower today than in March 2010, by a total of 698,000 jobs, the Labor Department says. And in a recent survey, the National Association of State Budget Officers found that ''states plan to reduce the number of full-time employees again'' this year.
It is not entirely clear how private employers will respond, but as some government officials point out, businesses at least have the option of passing along some of the additional costs to consumers.
In Indiana, Daniel T. Tanoos, the schools superintendent for Vigo County, which includes Terre Haute, said, ''The school system has no way to increase prices as a private business can.''
To hold down the work hours of school bus drivers, Vigo County has reduced field trips for children and cut back transportation to athletic events. School employees who had two part-time jobs totaling more than 30 hours a week -- for example, bus driver and basketball coach -- were required to give up one of the jobs.
The Obama administration says ''there is absolutely no evidence'' of any job loss related to the Affordable Care Act. And the Congressional Budget Office says ''there is no compelling evidence that part-time employment has increased'' as a result of the law.
But economists tend to focus on the private sector, which employs more people and has been adding jobs, unlike the public sector.
Republicans in Congress like Representatives Tim Griffin of Arkansas, Mike Kelly of Pennsylvania and Todd Young of Indiana said they knew of public employers in their states that had restricted the hours of part-time employees.
Authors of the health care law wanted more people to have insurance, Mr. Griffin said, but he asked: ''What did they get? No insurance and less pay. Genius! That's a genius federal program right there.''
Community colleges depend heavily on part-time faculty members, who teach about 45 percent of all courses, according to the American Association of Community Colleges. The association praised the new rules, saying they would allow many community colleges to avoid the expense of providing health benefits to part-time faculty members.
However, the denial of benefits irks some instructors.
William J. Lipkin, an adjunct professor of American history and political science at Union County College in Cranford, N.J., said: ''The Affordable Care Act, rather than making health care affordable for adjunct faculty members, is making it more unaffordable. Colleges are not giving us access to health care, and our hours are being cut, which means our income is being cut. We are losing on both ends.''
The American Federation of Teachers lists on its website three dozen public colleges and universities in 15 states that it says have restricted the work assignments of adjunct or part-time faculty members to avoid the cost of providing health insurance.
The University of Akron, in Ohio, has cut back the hours of 400 part-time faculty members who were teaching more than 29 hours a week, said Eileen Korey, a spokeswoman for the school.
''We have more than 1,000 part-time faculty,'' Ms. Korey said. ''Four hundred would have qualified for health insurance. That would add costs that we cannot afford.''
URL: http://www.nytimes.com/2014/02/21/us/public-sector-cuts-part-time-shifts-to-duck-insurance-law.html
LOAD-DATE: February 21, 2014
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GRAPHIC: PHOTOS: Kyle Balch, left, and Dakota Rader are part-time sanitation employees in Medina, Ohio. Mr. Balch said he was not concerned with being limited to working 29 hours, but Mr. Rader called it a hit to his wallet. (A12)
Mayor Dennis Hanwell of Medina, Ohio, said the city had to cut hours or provide health care, ''and we could not afford the latter.''
Carol Stilla, center, a clerk in Medina's parks department, saw her hours drop from 38 a week to 35 and then to 29. (PHOTOGRAPHS BY MICHAEL F. MCELROY FOR THE NEW YORK TIMES) (A15)
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January 4, 2016 Monday
House Returns From Break With Plan to Send Health Care Repeal to Obama's Desk
BYLINE: CARL HULSE
SECTION: US; politics
LENGTH: 268 words
HIGHLIGHT: The House will open 2016 doing something Republicans have been itching to do for years: send a repeal of the Affordable Care Act to President Obama’s desk, even if it is unlikely they can override his veto.
The House returns this week from its holiday break, and it will open 2016 doing something Republicans have been itching to do for years: send a repeal of the Affordable Care Act to President Obama's desk.
"We owe it it to the country to take our best shot at repealing #Obamacare while Pres Obama is still in office," Speaker Paul D. Ryan said on Twitter in advance of the House's reconvening for the second session of the 114th Congress.
To reach their long-sought goal, House Republicans are planning to approve a Senate measure repealing the health care bill and stripping federal money for Planned Parenthood. It was passed under special budget rules that prevented Senate Democrats from using a filibuster to block, as they have in the past. But Republicans seizing the majority in the Senate will allow them to finally push the measure through to Mr. Obama.
The victory, while symbolic, will be short-lived. Mr. Obama will certainly veto a measure that repeals his signature domestic policy achievement. House Republicans will try to override the veto but cannot reach the necessary threshold without Democratic support.
But Republicans view forcing the president to reject the measure as meeting their promise to do whatever they can to overturn the legislation. They also hope it eases some conservative unrest over the recently approved budget deal struck with Democrats.
The Senate will not be back until next week, just in time for Mr. Obama's final State of the Union address.
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May 13, 2016 Friday
Health Care Ruling Gives John Boehner at Least Some Temporary Vindication
BYLINE: CARL HULSE
SECTION: US; politics
LENGTH: 294 words
HIGHLIGHT: A court ruling on Thursday gutting a central provision of the Affordable Care Act is the results of a suit initiated by Mr. Boehner before he was forced out of the speakership last year by a group of hard-right conservatives who said he was not aggressive enough in trying to repeal the health care law.
The Obama administration and its allies are confident that Thursday's federal court ruling, gutting an important part of the new health care law, will be overturned on appeal. But Republicans were not worrying about that for the moment. They were too busy celebrating the decision.
After years of complaints that the Obama White House was flagrantly exceeding its executive authority on a range of issues, a federal district court judge in Washington, Rosemary W. Collyer, agreed with Republicans on the Affordable Care Act, finding that Congress had not funded a $130 billion program providing subsides to insurance companies.
"This is a historic win for the Constitution and the American people," Speaker Paul D. Ryan said in a typical reaction. "The executive branch is being held accountable to We the People."
The victory was particularly sweet for former Speaker John A. Boehner, but it may have also been bittersweet. The suit was the brainchild of Mr. Boehner and members of his staff, who initiated it as a way to challenge the new health care law. They recognized that congressional Republicans were never going to be successful in repealing the health care law with Mr. Obama in the White House (i.e., the failed shutdown in 2013) and looked for a more fruitful way to undermine it.
Despite his efforts, Mr. Boehner was ultimately forced out of the speakership last year by a group of hard-right conservatives who viewed him as not aggressive enough in calling the administration to account. But their tactics failed, while his have produced some actual results, however the case ultimately turns out at the appeals court level.
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The New York Times
January 19, 2014 Sunday
Late Edition - Final
Rules for Equal Coverage by Employers Remain Elusive Under Health Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 1034 words
WASHINGTON -- The Obama administration is delaying enforcement of another provision of the new health care law, one that prohibits employers from providing better health benefits to top executives than to other employees.
Tax officials said they would not enforce the provision this year because they had yet to issue regulations for employers to follow.
The Affordable Care Act, adopted nearly four years ago, says employer-sponsored health plans must not discriminate ''in favor of highly compensated individuals'' with respect to either eligibility or benefits. The government provides a substantial tax break for employer-sponsored insurance, and, as a matter of equity and fairness, lawmakers said employers should not provide more generous coverage to a select group of high-paid employees.
But translating that goal into reality has proved difficult.
Officials at the Internal Revenue Service said they were wrestling with complicated questions like how to measure the value of employee health benefits, how to define ''highly compensated'' and what exactly constitutes discrimination.
Bruce I. Friedland, a spokesman for the I.R.S., said employers would not have to comply until the agency issued regulations or other guidance.
President Obama signed the health care law in March 2010. The ban on discriminatory health benefits was supposed to take effect six months later. Administration officials said then that they needed more time to develop rules and that the rules would be issued well before this month, when other major provisions of the law took effect.
A similar ban on discrimination, adopted more than 30 years ago, already applies to employers that serve as their own insurers. The new law extends that policy to employers that buy insurance from commercial carriers like Aetna, Cigna, Humana and WellPoint, or from local Blue Cross and Blue Shield plans.
This could eventually be a boon to workers, the administration says.
''Under the Affordable Care Act, for the first time, all group health plans will be prohibited from offering coverage only to their highest-paid employees,'' said Erin Donar, a Treasury spokeswoman. ''The Departments of Health and Human Services, Labor and the Treasury are working on rules that will implement this requirement.''
The enforcement delay is another in a series of deadline extensions, transition rules, policy shifts and other steps by the Obama administration to minimize disruption from the new health care law, which is sure to be invoked by both Democrats and Republicans running for office this fall.
In recent months, the administration has delayed a requirement that larger employers offer coverage to full-time employees and delayed online enrollment in the federal insurance exchange for small businesses. It waived major provisions of the 2010 health law so consumers could renew policies that would otherwise have been canceled or terminated because they did not meet the law's coverage requirements.
In addition, federal officials announced that people with canceled insurance policies could obtain hardship exemptions sparing them from tax penalties if they went without insurance this year.
One of the questions facing the I.R.S. is whether an employer violates the law if it offers the same health insurance to all employees but large numbers of low-paid workers turn down the offer and instead obtain coverage from other sources, like a health insurance exchange.
Some health insurance arrangements will almost surely be forbidden, officials said. For example, they said, employers will not be able to provide coverage only to management.
Likewise, the officials said, a company could not provide free coverage to ''highly compensated individuals'' while requiring other employees to pay, for example, 25 percent of the cost. In addition, they said, benefits available to the dependents of highly paid executives must be available on the same terms to dependents of other employees in the health plan.
Under the 2010 law, an employer that has a fully insured health plan that discriminates in favor of high-paid executives could face a steep penalty: an excise tax of $100 a day for each individual affected negatively.
Thus, if a company had 100 employees and its health plan were found to discriminate in favor of 15 executives, the employer could be subject to a tax penalty of $8,500 for each day of noncompliance, for the 85 employees discriminated against. If the discrimination continued for 10 days, the penalty could be as much as $85,000.
If a company with 60 employees failed to meet the new standards with respect to half its employees for a year, it could face a penalty of $1 million.
One reason for the delay in enforcement is that officials have decided to review the existing nondiscrimination rules for self-insured companies, even as they try to write new rules for employers that buy commercial health insurance.
The existing restrictions on self-insured health plans are ''outdated, inadequate and unworkable,'' said Kathryn Wilber, a lawyer at the American Benefits Council, which represents many Fortune 500 companies.
Under the earlier law, all health benefits provided to highly compensated individuals -- with the possible exception of certain executive physicals -- are supposed to be provided to rank-and-file employees.
But employers say they may have legitimate reasons for wanting to offer different benefits to different workers.
''Employers should be permitted to provide lower-cost coverage to employees who may not be able to afford the comprehensive coverage being provided to other employee groups,'' Ms. Wilber said.
Katie W. Mahoney, the executive director of health policy at the U.S. Chamber of Commerce, said the existing nondiscrimination rules were so convoluted that employers often complied just with the spirit of the law, ''rather than with the precise requirements of the regulations.''
''Employers are likely to have difficulty complying with the new nondiscrimination requirement'' as well, Ms. Mahoney said.
She said the administration should scrap the existing rules and replace them with ''a single set of nondiscrimination rules and a single set of penalties for all types of group health plans.''
URL: http://www.nytimes.com/2014/01/19/us/rules-for-equal-coverage-by-employers-remain-elusive-under-health-law.html
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March 3, 2014 Monday
Late Edition - Final
New Law's Demands on Doctors Have Many Seeking a Network
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; REMAKING MEDICINE; Pg. 1
LENGTH: 2624 words
TAYLORSVILLE, Ky. -- Dr. Sven Jonsson, a primary care physician in this rural community, is seeing a steady tide of new patients under President Obama's health care law, the Affordable Care Act. And so far, it is working out for him. His employer, a big hospital system, provides expensive equipment, takes care of bureaucratic chores and has buffered him from the turmoil of his rapidly changing business.
''This is just a much saner place for me right now,'' said Dr. Jonsson, 52, who left private practice to work for the system, Baptist Health, in 2012. ''I'm probably going to live another five years.''
About 25 miles away in the more affluent suburb of Crestwood, Dr. Tracy Ragland, 46, an independent primary care physician, is more anxious about the future of her small practice. The law is bringing new regulations and payment rates that she says squeeze self-employed doctors. She cherishes the autonomy of private practice and speaks darkly of the rush of independent physicians into hospital networks, which she sees as growing monopolies.
''The possibility of not being able to survive in a private practice, especially primary care, is very real,'' she said.
Dr. Jonsson and Dr. Ragland represent two poles of that primary care system. Both live and work on the outskirts of Louisville, with the patience required of family practitioners who spend long days troubleshooting routine problems like back pain and acid reflux. But the similarities in their practices end there.
About 265,000 residents of Kentucky have signed up for insurance through the Affordable Care Act, and most have been found eligible for Medicaid, which the state expanded under the law. Primary care offices are supposed to be their point of entry into the health care system, providing the preventive care and upkeep that are crucial to improving the nation's health.
As an independent physician, Dr. Ragland must carefully devise strategies to keep her three-person practice afloat amid rising overhead, flat or dropping reimbursement rates, and new federal rules, many of them related to the health care law.
She said that she embraced the goal of extending health coverage to far more Americans, but that Medicaid paid too poorly for her to treat any of the new enrollees. And while she is accepting some of the private plans sold through Kentucky's new online insurance exchange, she has rejected others -- again, because she considers the payment too low.
Only about 40 percent of family doctors and pediatricians remain independent, according to the American Medical Association -- and many, including Dr. Ragland, feel that harsh economic winds that were already pushing against them have been accelerated by the Affordable Care Act.
''We're in an unknown time,'' she said.
Dr. Jonsson is less mired in the daily worries of running a medical business. His hospital system, with far more bargaining power than a private practice, negotiates with insurers on his behalf, pays his overhead and malpractice insurance, and handles much of the ever-expanding paperwork. It provides him with an X-ray machine and a costly system for keeping digital patient records, a move encouraged by the new law. He has been able to take his first long vacations in years, including a recent month in his native South Africa.
''It's that stability factor,'' Dr. Jonsson said. ''People know they can get a certain amount of salary, and the hospital's not going anywhere, you know?''
Since the passage of the act in 2010, hospital systems have been acquiring physician practices to shore up their market positions and form networks to take advantage of incentives under the new law. For now, Baptist is taking a financial hit by putting so many doctors on staff: Moody's Investors Service downgraded its credit rating in September, citing ''increased losses from an aggressive and rapid physician employment strategy.''
Baptist enlisted about a dozen of its primary care providers in the Louisville region to take on new Medicaid patients, officials there said, both to get more paying customers in the door and, as a nonprofit system with a stated charitable mission, to help more of Kentucky's poor get medical care under the law.
''We all have to sort of dig in and work hard and see what happens,'' Dr. Jonsson said.
Unhurried Visits
Dr. Ragland is both a general internist and a pediatrician, treating infants to patients in their 90s. Her office is on a winding road lined with horse pastures and upscale subdivisions, with a big sun-splashed waiting room and a Pilates studio next door. She grew up on a farm and does not bother wearing a white coat.
One Monday this month, she saw 15 patients at an unhurried pace, partly because she had some no-shows because of bitterly cold weather.
There was Marcia Robinson, 54, who learned she had shingles in December and was seeking follow-up care before a Caribbean vacation; Dylan Waddle, 10, who had a bad cough; and Margaret Smith, 77, who was dealing with a painful wisdom tooth.
''She's very attentive,'' Mrs. Smith, a retired piano teacher, said of Dr. Ragland. ''She doesn't just cut you off.''
Dr. Ragland has seen a handful of newly insured patients since Jan. 1, but most of her adult patients have insurance through their jobs or Medicare. Some have switched to the new private exchange plans that her office takes -- all except those offered by Humana, a large insurer based in Louisville, which she said would have reimbursed 20 percent less than what her office gets for Humana plans outside the exchange. Still, she does not hesitate to recommend the exchange to her patients if she thinks it could help them.
Halfway through her day, Dr. Ragland walked into an exam room and found Aline Burgin, 61, waiting for her. ''I haven't seen you in a while!'' she said, noting that Ms. Burgin's last visit was two years earlier. Ms. Burgin, who works the overnight shift at a nursing home, said she had temporarily dropped her employer-sponsored insurance because it was too expensive.
''It's $170 out of my paycheck every two weeks,'' she said.
''Did you go to the exchange to see if you could qualify for some help?'' Dr. Ragland asked.
Ms. Burgin agreed to take the phone number for Kynect, the state exchange. Then she lingered in the exam room, telling Dr. Ragland about her sister's recent death from emphysema and the guilt she felt about not being with her that day. Dr. Ragland listened for nearly 10 minutes, nodding her head and saying, ''Mm-hmm.''
By the time they were finished, 30 minutes had passed -- 10 minutes longer than the usual appointment time. It is that kind of flexibility that Dr. Ragland said she treasured about private practice.
''Some patients need five minutes; some patients need all kinds of time and follow-up,'' she said. ''I never want to be in a situation where my employer tells me I need to be more productive or I'm going to have a severe cut in my pay.''
The next morning, Dr. Ragland and her partners had their monthly meeting with a private consultant they hired recently to take over their billing and help them maximize reimbursements. They talked about their effort to recruit a fourth partner, which has stalled partly because so many young doctors now prefer to work for hospitals. And they examined spreadsheets showing their productivity over the previous month, including how many patients each doctor had seen and how much they had billed for each visit. Productivity was down because of harsh weather.
''I want to rent a truck and pick up patients and say, 'Go to the doctor!' '' said the consultant, January Taylor-Mills.
One investment Dr. Ragland has delayed making is in a sophisticated electronic records system; for now the doctors are using what Ms. Taylor-Mills called a ''very basic'' model that is essentially free but not as comprehensive as those used by hospital systems.
As a survival tactic, the practice has joined an ''accountable care organization'' -- a network of physicians, in this case independent, who coordinate care for a group of patients. These networks, encouraged by the new law, reap financial rewards if they improve patients' health and spend less doing it. Dr. Ragland said her accountable care organization is eager to prove that it can succeed ''at probably lower cost than a lot of the hospital systems.''
Ms. Taylor-Mills asked the partners if they were aware that under the Affordable Care Act, primary care doctors could temporarily get reimbursed for seeing Medicaid patients at much higher Medicare rates. The doctors were unmoved; the law raised the rates only for 2013 and 2014.
''It'll go back down,'' said one, Dr. Tony Karem. ''It's all a big game, I think.''
An Influx of Patients
In his Baptist Medical Associates office across from a drab shopping center in Taylorsville, Dr. Jonsson chugged through 30 patient visits one Wednesday in January. He hustled between exam rooms carrying a laptop equipped with voice recognition software, provided by Baptist, that allows him to dictate notes into patients' digital records.
''There's no question I have more time,'' he said, comparing his life now to when he owned a private practice. But, he added, ''I work hard when I'm here.''
For now, hospitals generally provide doctors like him with a baseline salary and potential bonuses tied to productivity -- a system likely to change as the Affordable Care Act calls for basing payment on results instead of volume.
His office is utilitarian: a single long hallway lined with exam rooms that Dr. Jonsson, a nurse practitioner and a physician assistant shuttle between. In the waiting room, fliers for other Baptist services -- weight-loss surgery, addiction treatment, home health aides -- share rack space with magazines like Field and Stream.
Dr. Jonsson, a competitive kayaker who advocates a plant-based diet to anyone who will listen, quickly dispensed with a back pain case and a follow-up visit for chest pain that seemed to be acid reflux. There were also patients with leg cramps, obsessive compulsive disorder, pneumonia and rheumatoid arthritis, most of whom had followed Dr. Jonsson when he went to work for Baptist -- or as Steven Pippin, the chest pain patient, put it, ''when Obamacare came along.''
Down the hall, Melissa Thomas, the physician assistant, was examining Craig Dooley, a newly insured patient who had limped into Dr. Jonsson's office with a catalog of ailments, including pain in his knees and shoulders. A physical exam, his first in more than six years, turned up other concerns: possible heart and prostate problems that called for referrals to specialists. He had traveled about 20 miles from Louisville, he said, because he could not find a doctor who would take his newly acquired Medicaid closer to home.
''I wouldn't normally come all this way,'' said Mr. Dooley, 56, who left with referrals to an orthopedist, a urologist and a cardiologist, and an appointment for an overdue colonoscopy. ''But I can't complain. This is good insurance, and I'm overjoyed by having it.''
Dr. Jonsson is accepting new Medicaid patients under the Affordable Care Act because his rural practice has room to grow, said Donna Ghobadi, an assistant vice president at Baptist. In particular, Ms. Thomas and Darline Caldwell, the nurse practitioner, are still building their patient base; Baptist considers these types of providers, who have less training but work with doctors as a team, crucial to taking on new patients in the Affordable Care Act era.
''It's a way to expand capacity without maybe so much the cost of a physician,'' Ms. Ghobadi said.
Dr. Jonsson owned his practice in Louisville for a decade -- and did not accept Medicaid, for the same reasons that Dr. Ragland generally does not -- but sold it in 2010, months after the Affordable Care Act passed. He did so, he said, expressly out of concern that the law and related requirements were about to ratchet up the pressures and expense of private practice. In particular, he dreaded having to buy and learn how to use an electronic records system, not only because such systems are expensive but because doctors' productivity slows down while they are learning the computerized systems, threatening tight margins.
''I'm not sure how I could have done it,'' Dr. Jonsson said.
When he is done seeing patients, he tends to the grapevines he recently planted on his property with plans to make wine.
''I don't have to go look at anything related to the finances of the office,'' he said. ''I can actually go dig a hole on my farm.''
Support for Doctors
On a recent blue-sky morning, Dr. Ragland drove to the State Capitol in Frankfort with a mission: proposing that Kentucky provide scholarships to medical and nursing students who agree to practice primary care in underserved areas for at least three years. She is on the board of the Greater Louisville Medical Society -- part of an attempt to become ''more outward-looking,'' she said -- and wants to offer ideas for easing a worsening shortage of primary care doctors.
She sat down with State Representative Larry Clark, the Kentucky House speaker pro tem, and State Representative Jimmie Lee, who oversees the House human services budget. Mr. Lee peered at her, arms crossed, as she made her pitch. Money was tight, he told her, and a new bill that would give experienced nurse practitioners more leeway to practice independently -- being voted on by a committee that day -- would likely do more to address access issues because there would never be enough primary care doctors.
''I've got seven doctors in my family, and there's not one of them who's a family practice doctor,'' Mr. Lee said. ''I'll tell you why: because they don't make any money.''
Dr. Ragland smiled, resolute. ''Listen, I'm pro-nurse practitioner -- very much,'' she said. ''There's no question we have to have them, but until we supplement their training they can't substitute for us, representative.''
The lawmakers suggested a second meeting with members of Gov. Steven L. Beshear's administration and ushered Dr. Ragland out. She made her way to the building's cafeteria, where a group of nurse practitioners were celebrating the unanimous committee vote in favor of the bill expanding their authority.
''I don't get the emphasis on primary care is so important, but primary care physicians aren't,' '' she said, sitting across the room from the group.
Over the following weeks, the nurse practitioner bill won passage in the Legislature, and Governor Beshear signed it into law. Dr. Ragland had another meeting with the lawmakers, who agreed to keep discussing her proposal and perhaps bring some version of it to the Legislature next year.
In Taylorsville, the new patients are still coming. Dr. Jonsson's practice has seen dozens of them -- even though he left on Jan. 17 for five weeks in South Africa, where he helped at a remote clinic. While he was gone, Ms. Caldwell, the nurse practitioner, and Ms. Thomas, the physician assistant, handled the patient flow.
He had never been able to take more than a week off in private practice, he said -- ''if you did, you really didn't earn anything that month because it all went to overhead'' -- and Baptist's willingness to let him do so was another source of new happiness. The typical fears about hospital employment -- pressure to refer only to other Baptist doctors, for example, or to bring in as much revenue as possible -- have not burdened him, he said, at least not yet.
''I don't know where I'll be in 10 years,'' he said, acknowledging that the uncertainty pervading his profession may lead him down yet another path. ''Hopefully I'll be here and hopefully I'll be happy, right?''
REMAKING MEDICINE: Articles in this series are examining how the Affordable Care Act is affecting lives in one American city.
URL: http://www.nytimes.com/2014/03/03/us/new-laws-demands-on-doctors-have-many-seeking-a-network.html
LOAD-DATE: March 3, 2014
LANGUAGE: ENGLISH
GRAPHIC: PHOTOS: Dr. Sven Jonsson, employed by a hospital system in Kentucky, examined Bob Stanley. (A1)
CRAIG DOOLEY, a new Medicaid recipient examined for the first time in six years at Dr. Sven Jonsson's office (PHOTOGRAPHS BY LUKE SHARRETT FOR THE NEW YORK TIMES)
Dr. Tracy Ragland, with Kelli Van Zant, above, in December at her office in Crestwood, Ky. The doctor said that she supported extending coverage to more Americans but that Medicaid paid too poorly for her to treat any of the new enrollees in her private practice. At left, a sign in Taylorsville, Ky., for the office of Dr. Sven Jonsson, who works for Baptist Health, a large hospital system. (PHOTOGRAPHS BY TYLER BISSMEYER FOR THE NEW YORK TIMES
LUKE SHARRETT FOR THE NEW YORK TIMES) (A14)
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The New York Times
January 22, 2017 Sunday 00:00 EST
Trump's Vow to Repeal Health Law Revives Talk of High-Risk Pools
BYLINE: REED ABELSON
SECTION: BUSINESS
LENGTH: 1482 words
HIGHLIGHT: Some lawmakers are pushing the idea of the pools, which in the past left many people with pre-existing conditions uncovered or with strict limits to health care.
Joanne Fitzgerald was getting divorced and was stressed out. When stomach pain kicked in, she saw a doctor to have it checked out.
That was her mistake.
The doctor diagnosed a mild form of gastritis, an inflammation of the stomach lining, and recommended some over-the-counter medicine. But when the divorce became final, in 2008, she lost health coverage from her husband's employer, and insurer after insurer refused to cover her because of the condition. She was finally offered a policy that excluded coverage for anything related to her gastrointestinal tract.
"I thought I was being smart in going to the doctor and getting checked out," Ms. Fitzgerald, 55, who currently lives in Washington, D.C., said recently. "Then I tried to go get insurance and everyone denied me."
Her fortunes changed under the Affordable Care Act, the major health law signed by President Barack Obama that required insurers to cover pre-existing medical conditions. She was one of the millions of people who jumped at the opportunity and bought a policy available under the new law.
Now, after President Trump and the Republican-controlled Congress have vowed to repeal and replace the health law, one of the most vexing questions is whether people like Ms. Fitzgerald will be covered.
About 27 percent of people under 65 are thought to have some sort of pre-existing condition that will most likely leave them without individual insurance if the law is repealed, according to a recent study. The guarantee of coverage has already become a rallying cry for people who want to keep the law.
The issue "is the third rail" for the Republicans, said Michael Turpin, a longtime health industry executive.
Before the law, a fairly typical life event - like a divorce or the loss of a job - and a relatively minor medical condition could upend a person's health coverage options. Stories of sick people unable to get coverage when they needed it most were legion.
Mr. Trump insists he wants to keep the pre-existing requirement for insurers, and other top Republicans say people who want coverage should not be turned away. Details about how they will cover people with existing medical conditions have not yet emerged, but many lawmakers have started pushing an idea - known as high-risk pools - that left many people uncovered or with strict limits to their coverage in the past.
The challenge for lawmakers is this: How do you get insurers to cover people who will definitely need costly medical care - and do so without making insurance too expensive for everyone?
The Affordable Care Act addresses that question by requiring everyone to get coverage or face a tax penalty. That mandate is meant to increase the number of healthy people who have insurance, distributing the costs of caring for those who are sick across a wider population. The thinking is that if enough healthy people sign up, the costs of sick people will be offset for insurers.
Top Republicans, though, say the system is not working and point to double-digit price increases for premiums.
"There is a better way to fix that problem without giving everybody else all these massive premium increases," the House speaker, Paul D. Ryan, said at a recent televised forum.
Finding a fix is far from simple. Before the law was passed, insurance companies evaluated the health of each person applying for coverage before offering a policy, and priced the plan to reflect the possible cost of care. The companies wanted to minimize the risk of losing money by paying for costly medical care for too many of their customers.
Often, insurers offered no options to people with pre-existing conditions, because they considered the potential costs to be too high. As a result, 35 states had high-risk pools, the program again on the lips of top lawmakers, including Mr. Ryan.
The high-risk programs offered a separate insurance pool for people with potentially expensive medical conditions. The idea is that by separating sick people from the majority of people who are healthy, insurers could offer cheaper rates to the healthy people. Insurers could charge higher prices to those with existing medical conditions, but they would also rely on other sources of funding, including from the government, to cover their costs.
The system worked for Dan Nassimbene and his wife, who had breast cancer but is in remission. They enrolled in Colorado's high-risk pool for three years. She paid about $375 a month for a plan that covered most of her treatments.
In 2014, though, the high-risk pool was closed, and Mr. Nassimbene bought a plan that met the requirements of the Affordable Care Act. The cheapest plan he could buy for himself and his wife cost around $900 a month and came with a family deductible of around $12,000, much higher than it was before. His income was too high for him to receive any government subsidies, which help about 80 percent of people buying such plans.
"I had coverage but no access," said Mr. Nassimbene, 55. He has since switched to a Christian health care sharing ministry, in which members cover one another's medical bills. It does not qualify as coverage under the law.
In many cases, the high-risk pools were overburdened financially, leaving many people without insurance or with tight restrictions on coverage. Insurers refused to cover the individuals who were likely to have the highest expenses, like those who had H.I.V. or serious kidney disease, and the pools lost money.
Many states had to turn applicants away - in some states, only a small percentage of those who applied received coverage - and the insurance was sharply limited to control spending.
In Washington, over 80 percent of the people referred to the state's high-risk pool never got health insurance, said Mike Kreidler, the state's insurance commissioner. In California, which relied on lawmakers to allocate money as part of the state budget, there was a waiting list, recalled Richard Figueroa, who was a senior administrator for the program.
The pool operated on a first-come-first-served basis, Mr. Figueroa said, without regard to people's income or the severity of their medical condition.
"There were people literally dying on the waiting list," he said.
In addition, most of the states offering coverage had caps on payments for medical care. Washington's annual maximum was $2 million, while California's limit was $75,000 a year. Under the Affordable Care Act, insurance plans cannot have such a limit.
In California, the program dwindled away until it served only 6,300 at the end of 2011.
Dennis Carr, for example, worked as an independent real estate agent when the financial markets crashed in 2008. He had savings, but he eventually had to drop his Blue Cross plan because his income had tailed off and he could not afford it. Mr. Carr, who is now 51, said his goal was to resume coverage as soon as he was financially secure.
When he reapplied to the same insurer a few months later, he was rejected - and then rejected again by another insurer because of his asthma and a sinus condition.
"It was just a real, real slap," Mr. Carr said.
He was directed to California's high-risk pool but found the premiums too high. He moved to Mexico as a way to afford his medications. He now lives in Phoenix, where he has coverage through an employer.
"For all the thousands of people who self-selected out because they couldn't afford it, it broke our hearts on a daily basis," Mr. Figueroa, the California official, said.
For others, the coverage offered by the high-risk pools was too limited for them to receive the care they needed.
Beth Martinez, 40, who has multiple sclerosis, was forced to join Texas' high-risk pool when she and her husband moved to Austin. Only six visits to the doctor were covered, and she found she could not afford the annual M.R.I. recommended to monitor her disease because of her high deductible. At one point, she said, she went four years without an M.R.I.
She and her husband now live in California and are covered through private plans offered through that state's marketplace, which meet all the health law's requirements for pre-existing conditions. Because she can work only part time, she is eligible for federal subsidies, which bring the couple's costs to $70 a month. Ms. Martinez had paid $275 a month in the Texas pool to cover herself, and her husband was uninsured.
She now gets the M.R.I.s she needs under her plan, and her policy even pays for physical therapy, which allows her to put in longer hours at her job as a hairstylist and makeup artist.
That sort of quality coverage, Ms. Martinez said, is a big departure from what she had through the high-risk pool, adding that "it was definitely some of the worst insurance I had in my life."
PHOTO: Joanne Fitzgerald was repeatedly rejected by health insurers before she was able to get coverage under the Affordable Care Act. (PHOTOGRAPH BY MATT ROTH FOR THE NEW YORK TIMES) (A17)
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March 31, 2016 Thursday
The New York Times on the Web
The 1095 Tax Form for Health Care Coverage: What You Need to Know
BYLINE: By ANN CARRNS
SECTION: Section ; Column 0; Business/Financial Desk; YOUR MONEY ADVISER; Pg.
LENGTH: 812 words
Millions of Americans who have health coverage through a big employer are receiving a new, unfamiliar tax form in the mail this year, thanks to the Affordable Care Act: the 1095-C.
Most tax filers do not need to do much with it, except file it away with their tax records. But because it is new, the form is causing a bit of confusion, said Victor Saliterman, vice president and general manager for health care reform at the benefits and payroll administrator ADP.
This is the first time in decades that a major new employee tax form has been widely distributed, Mr. Saliterman said, and many workers do not know what to do with it when it arrives. (The familiar W-2, the form that details employee wages, dates to the early 1940s.) ''This is definitely new ground,'' he said.
So what is a 1095-C? It is a form for health care, sent to people who have health insurance through a large employer. The maker of TurboTax, the do-it-yourself tax software, estimates that about 65 million people are getting the 1095-C form this year.
The 1095-C is created and sent by your employer, which also sends a copy to the Internal Revenue Service. It contains information about the type of health coverage that your employer offered for the prior year -- essentially showing that the employer made affordable health coverage available. It also shows the premium for the lowest-cost plan offered, which may differ from what you paid if you chose a more expensive option.
The form also may show what months you and your family were covered, so it serves as official proof of insurance -- helpful to have in case you are audited, Mr. Saliterman said, because the Affordable Care Act requires most people to have health insurance, or pay a penalty.
The ''C'' is actually one of three versions of Form 1095. People who bought coverage through the federal or state health insurance exchanges get the 1095-A. A grab bag of others, including workers at small employers and those with government health insurance, like Medicaid, get a 1095-B, which is also new this year. Pretty much everyone with health insurance should get one of the forms. TurboTax has an online tool to help you understand which one to expect.
It is not necessary to file the 1095-C (or versions A or B, for that matter) with your tax return. Rather, filers should check the form for accuracy, use any information needed, and then store it along with other important tax documents, said Debra Hammer, a spokeswoman for Affordable Care Act topics at Intuit, the maker of TurboTax. Generally, she said, you should keep tax returns and supporting documentation for at least three years.
Because the 1095-C form is new and companies are getting used to preparing it, recipients should check carefully to make sure that the form accurately reflects their health coverage for the prior year, said Jeffrey Martin, a member of the American Institute of Certified Public Accountants' health care task force. If there is any discrepancy, he said, filers should report it by calling the contact number listed on the form.
More information about the forms is available online from the I.R.S. and from the Tax Institute at H&R Block.
Here are some questions about health insurance tax forms:
â- What if I have not yet received a Form 1095-B or C?
Employers are required to send out the forms by March 31. So if you have not received one by next week, contact your benefits department.
But do not delay filing your tax return if you do not have the form, the I.R.S. advises.
Most people do not need the information on the form to complete their tax return, and can use other records -- like payroll statements, insurance cards or benefits documents -- to confirm coverage, if necessary.
â- What if I had marketplace coverage and have not received a Form 1095-A?
Unlike other versions of the form, the 1095-A is crucial to filing a return, because it has information necessary to reconcile any premium tax credit you received. So you should not file a return unless you have it in hand, the I.R.S. says. Most people should have received the form already. If yours has not arrived, visit HealthCare.gov or your state exchange to download an electronic copy.
â- Can I receive more than one version of Form 1095?
Yes. You may get multiple forms, depending on the details of your job and health coverage during 2015, said Lindsey Buchholz, a program manager at the Tax Institute at H&R Block. If, for example, you were self-employed and had marketplace coverage for several months, then got a new job and switched to workplace health insurance, you should receive a 1095-A from your marketplace insurer and a separate form from your new employer.
It is possible, she added, that you may get two different forms even if you did not change jobs, depending on the details of how your employer administers its health coverage.
URL: http://www.nytimes.com/2016/03/31/your-money/taxes/the-1095-tax-form-for-health-care-coverage-what-you-need-to-know.html
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(First Draft)
September 21, 2015 Monday
Hillary Clinton, in Louisiana, Gets a Health Care Challenge From Bobby Jindal
BYLINE: MAGGIE HABERMAN
SECTION: US; politics
LENGTH: 174 words
HIGHLIGHT: Hillary Rodham Clinton has a campaign stop in Louisiana, where the governor there, the Republican presidential candidate Bobby Jindal, hopes to gain some attention with their differences on health care.
Gov. Bobby Jindal, looking for traction in the Republican presidential nomination contest, is welcoming Hillary Rodham Clinton on Monday to his home state of Louisiana, where she plans to hold an event stressing the positive effects of President Obama's health care law.
Mr. Jindal issued a statement in advance of the visit, challenging Mrs. Clinton to a debate on the Affordable Care Act.
"Secretary Clinton is the godmother of socialized medicine," Mr. Jindal said in the statement. "The government takeover of our health care system started with HillaryCare in the 1990s."
Mr. Jindal is among the Republican contenders who favor repealing and replacing the health care law.
Mrs. Clinton is using events in Louisiana, Arkansas and elsewhere to focus attention on the ways in which the health care law has helped families. She is also focusing a plan for containing prescription drug costs.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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July 19, 2013 Friday
Late Edition - Final
Speaking Out for Health Care Act, Obama Says Millions Will Get Rebates
BYLINE: By MARK LANDLER
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 701 words
WASHINGTON -- President Obama, slipping back into his episodic role as a vigorous campaigner for his new health care act, said Thursday that thanks to the law, more than 8.5 million Americans are getting rebates this summer from their insurance providers.
Mr. Obama was joined by families who have benefited from a provision in the law, which requires health insurers to spend at least 80 percent of the revenue from premiums on medical care rather than on administrative costs. Insurers who fail to meet that benchmark must reimburse customers, a process that began in 2012.
''Last year, millions of Americans opened letters from their insurance companies, but instead of the usual dread that comes with getting a bill, they were pleasantly surprised with a check,'' Mr. Obama said in a midday ceremony at the White House.
The checks typically amount to no more than a few hundred dollars. But the president, recounting the stories of middle-class families arrayed on the stage behind him, celebrated these modest windfalls as an early sign of the tangible benefits of the law.
For Mr. Obama, it was a high-profile return to a debate in which his voice has sometimes seemed absent. For example, he has said nothing publicly about the administration's decision to delay for a year a part of the law dealing with employer-provided insurance.
With the Republican-controlled House of Representatives voting yet again this week to repeal the Affordable Care Act, however, he seized on new statistics that demonstrate the law is driving down premiums in New York, California and several other states.
The Department of Health and Human Services released a report Thursday asserting that in 11 states and the District of Columbia, proposed health insurance premiums for 2014 were nearly 20 percent lower than the administration had projected.
''Today's report shows that the Affordable Care Act is working to increase transparency and competition among health insurance plans and drive premiums down,'' Kathleen Sebelius, the secretary of health and human services, said in a statement.
In New York, state insurance regulators said they had approved rates for 2014 that were an average of at least 50 percent lower than those now available. Administration officials attribute much of that decline to online purchasing exchanges, set up by the law, which they say encourage more competition among insurance providers.
Thursday's choreographed event in the East Room was intended to put the White House back on the offensive on health care, after a messy period following its decision to delay requiring employers with more than 50 employees to offer health insurance, or pay a penalty.
The delay came after heavy pressure from businesses, which said the law was too complex and cumbersome to implement on time, and it provided critics with fresh ammunition for their claim that the law is putting unfair burdens on individuals and employers.
Republicans did not let up on Thursday, claiming that the benefits extolled by Mr. Obama would be more than offset by higher costs. In some cases, they did not even wait for him to speak.
''Even though we expect the president today to tout about $500 million of these types of refunds, what he won't say is that next year, Obamacare will impose a new sales tax on the purchase of health insurance that will cost Americans about $8 billion,'' said the Senate Republican leader, Mitch McConnell of Kentucky. ''That's a 16 to 1 ratio!''
In a statement after Mr. Obama spoke, Speaker John A. Boehner said: ''The picture the president paints of his health care law looks nothing like the reality facing struggling American families. They know that the law is turning out to be a train wreck.''
Mr. Obama dismissed these arguments as political gamesmanship in Washington, belied by the statistics from the states. As for the House's latest vote to repeal the act, he said Republicans were ''refighting old battles'' rather than confronting the nation's problems.
''I recognize that there are still a lot of folks -- in this town at least -- who are rooting for this law to fail,'' he said. ''Some of them seem to think that this law is about me. It's not. I already have really good health care.''
URL: http://www.nytimes.com/2013/07/19/us/politics/speaking-out-for-health-care-act-obama-says-millions-will-get-rebates.html
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GRAPHIC: PHOTO: Families who have already benefited from a rebate provision in the new health care law joined President Obama on Thursday for a ceremony at the White House. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)
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October 26, 2014 Sunday
Late Edition - Final
Insurers' Consumer Data Isn't Ready for Enrollees
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 21
LENGTH: 830 words
WASHINGTON -- With health insurance marketplaces about to open for 2015 enrollment, the Obama administration has told insurance companies that it will delay requirements for them to disclose data on the number of people enrolled, the number of claims denied and the costs to consumers for specific services.
For months, insurers have been asking the administration if they had to comply with two sections of the Affordable Care Act that require ''transparency in coverage.''
In a bulletin sent to insurers last week, the administration said, ''We do not intend to enforce the transparency requirements until we provide further guidance.'' Administration officials said the government and insurers needed more time to collect and analyze the data.
''We expect this will begin after a full year of claims data is available,'' said Aaron Albright, a spokesman at the Centers for Medicare and Medicaid Services, when asked about the government's eventual plan to enforce the transparency requirements.
Consumer advocates said they were disappointed because the information would be helpful to millions of consumers shopping for insurance in the open enrollment period that starts on Nov. 15. The data will not be available before the enrollment period closes on Feb. 15.
In a new poll from the Kaiser Family Foundation, nine of 10 uninsured Americans said they were unaware that open enrollment begins in November, and two-thirds of the uninsured said they knew ''only a little'' or ''nothing at all'' about the marketplaces.
Arming consumers with information was a major goal of Democrats, who wrote the health care law. It was signed by President Obama in March 2010.
Under the law, consumers in each state have access to a public marketplace, or exchange, where they can buy insurance and apply for federal subsidies to help pay premiums.
The law says each exchange shall require insurers to disclose their claims payment policies, ''data on enrollment, data on disenrollment, data on the number of claims that are denied, data on rating practices'' and information on the use of doctors and hospitals outside a health plan's network.
Moreover, the law says, insurers must allow consumers to ''learn the amount of cost-sharing (including deductibles, co-payments and co-insurance) under the individual's plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service.''
''At a minimum,'' the law says, ''such information shall be made available to such individuals through an Internet website'' and by other means for people without access to the web.
Sabrina Corlette, a research professor at the Health Policy Institute of Georgetown University, said it was ''disappointing and somewhat frustrating'' that the disclosure requirements had been delayed.
''This is a critical tool,'' said Ms. Corlette, who is also a consumer representative to the National Association of Insurance Commissioners. ''It would provide the federal government and states with a wealth of coverage data -- really important information to show if consumers are getting the full benefits of their coverage.''
Many people obtaining coverage under the Affordable Care Act have never had commercial insurance, and even experienced consumers are sometimes baffled by the intricacies of insurance policies, including provider networks and deductibles.
Insurers provide consumers with a ''summary of benefits and coverage.'' That document tells customers: ''You must pay all the costs up to the deductible amount before this plan begins to pay for covered services.'' Some insurers, however, help pay for some items and services before a consumer meets the deductible. It is not always clear which services are subject to the deductible and which are not.
A health maintenance organization offered by Blue Cross and Blue Shield of Florida illustrates the complexity. The plan has seven tiers of prescription drug coverage, including three just for generic drugs.
Under the plan, consumers pay only $4 for generic drugs used to treat certain chronic conditions like high blood pressure and diabetes. But for other generic drugs, as for some brand-name products, the insurance kicks in only after consumers have met the annual deductible ($2,100 per person and $4,200 per family for all goods and services).
Jon R. Urbanek, a senior vice president at Blue Cross and Blue Shield of Florida, said consumers had many questions because the pharmacy benefit ''has all those tiers and some confusion to it.'' To help answer the questions, Mr. Urbanek said, the company has 18 retail stores in Florida and will hold several thousand town-hall-style meetings.
More than 80 percent of people insured through the exchanges are entitled to subsidies. Contracts between the federal government and insurers include an unusual provision allowing insurers to terminate the agreements if the subsidies, under attack in several court cases, become unavailable in the federal exchange.
URL: http://www.nytimes.com/2014/10/26/us/insurers-consumer-data-isnt-ready-for-enrollees.html
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GRAPHIC: PHOTO: Shareda Green, center, met in March with Barbara Bloomfield, a volunteer in Pennsylvania, to sign up for insurance under the Affordable Care Act. The enrollment period for 2015 begins next month. (PHOTOGRAPH BY MATT ROURKE/ASSOCIATED PRESS)
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May 15, 2013 Wednesday
Patterns of Changes in Health Insurance
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 781 words
HIGHLIGHT: Well-paid employees are likely to retain their employer-provided health insurance under the Affordable Care Act, and lower-paid employees are likely to be shifted to insurance exchanges, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
A number of industries can expect big changes in employee health insurance in the next year or two, while others will continue with business as usual.
Beginning next year, states and the federal government intend to create opportunities for families to purchase health insurance, separate from their employers, through insurance "exchanges" in the states. Insurers and the federal government will heavily advertise the new plans. Most important, middle- and low-income families may qualify for valuable federal subsidies that will serve to reduce premiums and out-of-pocket health costs.
To qualify for subsidized exchange plans, workers cannot be offered affordable insurance by their employers. Paradoxically, employers will create subsidy opportunities for their middle- and low-income employees whenever they fail to offer health insurance.
On the other hand, an employer dropping its health insurance next year will put its high-income employees in a tough spot, because they will have to buy insurance on their own without the tax advantages they had in the past by obtaining health insurance through their employer. As a result, employers with relatively many high-income employees will be under pressure to keep their insurance, whereas an employer of middle- and low-income employees may find them asking for health insurance to be dropped from the employee benefit menu.
Administrative costs, rising premiums and other costs have already made a number of employers lukewarm about health insurance, but they offered it in order to attract employees who do not care to be uninsured or to end up on Medicaid. The new insurance opportunities that become available next year may give their employees enough of an alternative that the lukewarm employers can drop their plans.
Both of these situations are closely correlated across industries, which leaves me to suspect that we can readily predict the industries that will retain employer insurance and predict those that will drop whatever health benefits they currently have. The scatter diagram below displays Bureau of Labor Statistics data on several industries according to the percentage of their employees in families above three times the poverty line (horizontal axis) and the percentage of employers offering health benefits as of March 2012 (vertical axis).
I measured employees relative to three times the poverty line because that is the family income threshold beyond which the new exchange subsidies are less valuable than the income tax preference for employer-sponsored health insurance.
Industries like colleges, utilities and banking almost always offer health insurance, and about 80 percent of their employees will be getting a better deal on employer health insurance than they would from the exchange plans because their families are above three times the poverty line. For these reasons, I am confident that these industries will continue to offer health insurance to their employees in much the same way that they have in the past.
A couple of industries like "accommodation and food services" (i.e., restaurants), leisure and hospitality, administrative and waste services, and construction already have a mix of employers in terms of their health insurance offerings, so it would not be unusual from an industry perspective for those that currently have health plans to drop them during the next couple of years.
Moreover, the diagram shows how 45 to 60 percent of their employees do not come from families above three times poverty and therefore will have a significant federal health insurance subsidy waiting for them as soon as their employers drop coverage.
Employers that do not offer health insurance may be subject to penalties, but the penalties are not levied based on part-time employees, or levied on small employers, and even the penalties levied will be less than the subsidy opportunities created by an employer of middle- and low-income people that fails to offer health insurance.
For these reasons, I suspect that the stories we will hear about employers dropping insurance will disproportionately come from the industries shown in the lower left part of the scatter diagram, which collectively employ about 25 million people. Some employers in these industries have already discussed such plans.
Health Coverage Worthy of a Senator
Hammurabi's Code and U.S. Health Care
Small Companies and the Affordable Care Act
Health Reform, the Reward to Work and Massachusetts
Older Workers Could Benefit if Companies Drop Insurance
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February 19, 2017 Sunday
Late Edition - Final
Repeal the Health Law?
SECTION: Section SR; Column 0; Editorial Desk; LETTERS; Pg. 10
LENGTH: 1063 words
''It seems reasonable to ask what Republicans have been doing for the last seven years.''
To the Editor: Speaking to supporters a week before the election, Donald Trump promised that he would call a special session of Congress to ''repeal and replace Obamacare.'' ''We have to do it,'' he said, because ''it is a catastrophe.''
Since the Affordable Care Act became law in 2010, congressional Republicans tried more than 60 times to repeal it. Yet here we are, seven years later, and they have no consensus alternative. Less than a month ago, the president and the Republican leadership were telling us that it may be at least a year or more before an alternative is ready for congressional deliberation.
Now, with apparent endorsement from the White House, Speaker Paul D. Ryan has put forth a new plan outline to be drafted into legislation soon (news article, Feb. 17). But his plan fails to answer critical questions on costs and the number of people who will be covered, will likely run into significant resistance from the states, and may not even satisfy the most conservative House members.
With that backdrop, it seems reasonable to ask what Republicans have been doing for the last seven years. If the law is such a catastrophe, a replacement should have been ready to roll out immediately. Policy experts should have been extolling both its coverage and financial virtues to insurers, the public and the media. Favorable comparisons to the existing program should have been rolled out to build public support. Instead, there is nothing.
We have a president who is more focused on imaginary crowd sizes and bogus claims of illegal voting than on proposing his own health care alternative, and a congressional leadership team expressing an apparent newfound appreciation of how difficult replacement is compared with repeal.
For a party whose mantra during the eight years of the Obama presidency was ''no way,'' it has morphed into one of ''no clue.''
TOM QUALLEY
Southwick, Mass.
To the Editor: Re ''Obamacare Repeal Hits a Brick Wall'' (editorial, Feb. 8): According to your editorial, the Trump administration and/or congressional Republicans hope to replace Medicare with vouchers (no doubt skimpy) for private insurance. At the same time, they are considering allowing those private insurers to raise premiums for older people up to three and a half times as much as they charge younger people.
Under such an inhumane plan, the insurance industry will laugh all the way to the bank, and growing old will become another luxury that most Americans can't afford.
ANNE MACKIN
Boston
To the Editor: Republicans in Congress can't come up with an alternative to Obamacare, because Obamacare is the Republican plan, drawn from Romneycare in Massachusetts. President Barack Obama knew that he could not get a touchdown with the Democratic plan (single payer), so he lobbed the Republican plan to Congress.
The Republican Congress can't reconcile itself to a Democratic-sponsored Republican plan because that would redound to Mr. Obama's credit, which Mitch McConnell, the Senate majority leader, is still committed to denying him, even though he's no longer president.
The Republicans should get over their opposition to Mr. Obama and finally give the man his due: the Affordable Care Act, a fairly sound Republican health care system.
ROSS ZUCKER
Harrison, N.Y.
To the Editor: Critiques of the Affordable Care Act seem to consider steep price increases a failure of the law. But under the law, the price of insurance is determined by the cost of health care. The law provides that 80 to 85 percent of each premium dollar must go toward paying claims and activities to improve health care quality. Put another way, insurance company profits cannot exceed 15 to 20 percent.
Another cost-controlling measure is to ensure that younger, healthier people buy policies -- the vilified ''mandate.'' If people want to stabilize premiums, they need to support the mandate, as well as legislation to control medical costs.
SHARON MORRISON
Whitefish, Mont.
To the Editor: Re ''Sprint to Repeal the Health Law Slows to a Crawl'' (front page, Feb. 3): Jim Jordan, Republican of Ohio and a leader of the House's most conservative wing, says, ''We are looking to repeal this law, just like we told the voters we were going to do, just like we promised them we would do.''
The strange thing is that the people do not want Obamacare to be repealed and replaced; only Republican politicians want that. The same can be said for Social Security and Medicare; the people want both programs to remain the same!
BRANT THOMAS
Brooklyn
To the Editor: ''Grading Obamacare: Pass, Fail, Incomplete'' (The Upshot, Feb. 6) doesn't mention the law's less visible but profound successes.
After the law's passage in 2010, the nonpartisan Medicare trustees extended their estimate for the continued solvency of its hospital insurance fund to 2029 from 2017 and adjusted that estimate to 2028 last year. Yearly health care cost inflation for all Americans for the decade before the health law (2000-2010) averaged 7.9 percent a year and in the five years since, just 5 percent a year. The average family of four with employer-based insurance saved $3,600 in premium costs in 2016, compared with what they would have paid with pre-health law yearly premium inflation.
A 2015 study found that the health law's dependent coverage for children up to 26 years led to increased diagnoses of early-stage cervical cancer in young women under 25.
The health law requires all insurers to cover effective preventive services without patient cost-sharing, including expensive colonoscopy for colorectal cancer screening; a just-published 2017 study found an 8 percent increase (8,400) in the diagnoses of early-stage, and thus more treatable, colorectal cancers among Medicare beneficiaries.
Yes, first impressions count; early studies showed limited impact, but the evidence is accumulating for the Affordable Care Act's low-profile progress in improving, if not curing, our complex and confusing health system.
A.H. STRELNICK
Bronx
The writer is a professor of family and social medicine at the Albert Einstein College of Medicine, Montefiore Medical Center.
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URL: http://www.nytimes.com/2017/02/18/opinion/sunday/repeal-the-health-law.html
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The New York Times
March 23, 2014 Sunday
Late Edition - Final
When the Scientist Is Also a Philosopher
BYLINE: By N. GREGORY MANKIW.
N. GREGORY MANKIW is a professor of economics at Harvard.
SECTION: Section BU; Column 0; Money and Business/Financial Desk; ECONOMIC VIEW; Pg. 4
LENGTH: 927 words
Do you want to know a dirty little secret of economists who give policy advice? When we do so, we are often speaking not just as economic scientists, but also as political philosophers. Our recommendations are based not only on our understanding of how the world works, but also on our judgments about what makes a good society.
The necessity of political philosophy arises because most policies are good for some people and bad for others. For example, an increase in the minimum wage, as proposed by President Obama, may raise incomes for some low-wage workers, but it will cause some businesses to make smaller profits, some customers to pay more and some workers to lose their jobs.
Similarly, the Affordable Care Act has provided greater opportunity for some people to get health insurance, but it also caused cancellations for others who were previously happy with their insurance. Evaluating the overall effect of these policies requires balancing competing interests.
To strike this balance, many economists think in terms of a ''social welfare function'' that aggregates individuals' well-being into a summary measure. This approach dates back to the utilitarian philosophers of the 19th century, such as Jeremy Bentham and John Stuart Mill. The utilitarians suggested that each person in society receives a certain amount of happiness, or ''utility,'' from an allocation of society's resources. The job of policy makers, they argued, is to do their best to maximize the total utility of everyone in society. According to utilitarians, taking a dollar from Peter and giving it to Paul is justified if Peter's decrease in utility is smaller than Paul's increase, as would plausibly be the case if Peter is richer than Paul.
Philosophers have long debated the validity of utilitarianism as an ethical criterion. Some of the most famous thought experiments in this area involve what ethicists call trolley problems. Imagine that you are on a bridge and see a runaway trolley car below you, hurtling toward three children playing on the tracks. A fat man is standing next to you. You can push him off the bridge and into the path of the trolley, killing him but saving the children. What do you do?
If, like a true utilitarian, you have no trouble sacrificing the fat man, try another scenario. You are a doctor with four dying patients. One needs a new liver, one needs a new heart, and two need a new kidney. A perfectly healthy patient walks into your office for his annual checkup. Are you still willing to pursue the utilitarian course of action? At this point, almost everyone balks. Sometimes, respecting natural rights trumps maximizing utility.
Another problem with the utilitarian approach is that there is no objective way to compare one person's happiness with another's, especially when people have different preferences. Peter may work long hours at a dreary job to earn a high income because he gets a lot of utility from money. Paul may be forgoing a higher income for a job that requires fewer hours or offers more personal satisfaction because he doesn't care as much about money. In this case, equalizing incomes by moving a dollar from Peter to Paul could reduce total utility.
Perhaps the biggest problem with maximizing a social welfare function like utility is practical: We economists often have only a basic understanding of how most policies work. The economy is complex, and economic science is still a primitive body of knowledge. Because unintended consequences are the norm, what seems like a utility-maximizing policy can often backfire.
So, what is the alternative? At the very least, a large dose of humility is in order. When evaluating policies, our elected leaders are wise to seek advice from economists. But if an economist is always confident in his judgments, or if he demonizes those who reach opposite conclusions, you know that he is not to be trusted.
In some ways, economics is like medicine two centuries ago. If you were ill at the beginning of the 19th century, a physician was your best bet, but his knowledge was so rudimentary that his remedies could easily make things worse rather than better. And so it is with economics today. That is why we economists should be sure to apply the principle ''first, do no harm.''
This principle suggests that when people have voluntarily agreed upon an economic arrangement to their mutual benefit, that arrangement should be respected. (The main exception is when there are adverse effects on third parties -- what economists call ''negative externalities.'') As a result, when a policy is complex, hard to evaluate and disruptive of private transactions, there is good reason to be skeptical of it.
As I see it, the minimum wage and the Affordable Care Act are cases in point. Noble as they are in aspiration, they fail the do-no-harm test. An increase in the minimum wage would disrupt some deals that workers and employers have made voluntarily. The Affordable Care Act has disrupted many insurance arrangements that were acceptable to both the insurance company and the insured; these policies were canceled because they deviated from lawmakers' notion of the ideal.
To be sure, you can find economists favoring a higher minimum wage and the Affordable Care Act. They acknowledge that there are winners and losers but argue that, on the whole, these policies increase social welfare.
Perhaps they are right. But keep in mind that in making that judgment, they are relying on forecasts from a far-from-perfect science, as well as a healthy dose of their own political philosophy.
URL: http://www.nytimes.com/2014/03/23/business/economic-view-when-the-scientist-is-also-a-philosopher.html
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The New York Times
November 30, 2014 Sunday
Late Edition - Final
Suit on Health Law Puts Focus on Funding Powers
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 25
LENGTH: 917 words
WASHINGTON -- In mounting the latest court challenge to the Affordable Care Act, House Republicans are focusing on a little-noticed provision of the law that offers financial assistance to low- and moderate-income people.
Under this part of the law, insurance companies must reduce co-payments, deductibles and other out-of-pocket costs for some people in health plans purchased through the new public insurance exchanges. The federal government reimburses insurers for the ''cost-sharing reductions.''
In their lawsuit, House Republicans say the Obama administration needed, but never received, an appropriation to make these payments to insurance companies. As a result, they contend, the spending violates the Constitution, which says, ''No money shall be drawn from the Treasury, but in consequence of appropriations made by law.''
President Obama requested the money as part of the budget he sent Congress in April 2013, but Congress did not act on the request. Seeing the issue as an urgent priority, the administration began making the payments early this year, using money from a separate account established for tax refunds and tax credits.
''The cost-sharing reductions are really important and valuable,'' said Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group.
Under a standard insurance policy, for example, consumers might have to pay a deductible of $2,500 before the health plan starts to pay. But with cost-sharing subsidies, the deductible could be reduced to $750 or just $100. And the co-payment for a doctor's office visit could be cut to $15 from $45.
The lawsuit, House of Representatives v. Burwell, is the latest battle in a political war over the Affordable Care Act, which was adopted in 2010 without any Republican votes.
''Time after time, the president has chosen to ignore the will of the American people and rewrite federal law on his own without a vote of Congress,'' Speaker John A. Boehner of Ohio said. ''The House has an obligation to stand up for the Constitution, and that is exactly why we are pursuing this course of action.''
Congress provided an open-ended appropriation for tax refunds more than 30 years ago, and in the health care law it said the money could be used for tax credits that subsidize insurance premiums.
But in their lawsuit, House Republicans say, ''Congress has not, and never has, appropriated any funds'' for the cost-sharing reductions.
Both types of assistance, tax credits and cost-sharing reductions, are important to the goal of providing affordable health care to all Americans, Democrats say. The Congressional Budget Office estimates that the government will provide $855 billion worth of premium tax credits and $175 billion of cost-sharing subsidies in the coming decade.
Sylvia Mathews Burwell, the secretary of health and human services, who was previously the White House budget director, said officials were using the same account for both types of assistance ''to improve the efficiency in the administration of subsidy payments'' under the health care law.
The White House established a budget account for cost-sharing subsidies, but no money has been deposited in or paid from it.
In a report last year, the nonpartisan Congressional Research Service said it appeared that there was no appropriation for cost-sharing subsidies, in contrast to the tax credits, for which Congress has provided a ''permanent appropriation.''
Federal officials are usually meticulous about spending money for the intended purpose. Under a law known as the Antideficiency Act, federal employees are subject to civil and criminal penalties if they spend money in excess of appropriations. Agencies report 10 to 20 violations a year. Under another law, public funds can be used only for the purposes specified by Congress in appropriations.
However, Republicans face a significant hurdle in getting a court to rule on their lawsuit. They must first show that they have standing to challenge the administration's action. Courts often refrain from getting involved in disputes between Congress and the executive branch. Some judges have agreed to consider cases in which a house of Congress explicitly authorized a lawsuit claiming an ''institutional injury.''
James F. Blumstein, a professor of constitutional and health law at Vanderbilt University, said: ''There are many reasons for courts to avoid getting sucked into disputes like this. But if Congress ever has standing to raise an institutional claim, this is one of the best issues on which to do it, because the power to control spending through appropriations is an institutional prerogative of Congress under the Constitution.''
The House suit was filed two weeks after the Supreme Court agreed to hear a separate case challenging the tax-credit subsidies in three dozen states that rely on the federal insurance exchange.
The health care law says the tax credits shall be available to people buying insurance on an exchange ''established by the state.'' The Internal Revenue Service has allowed tax credits for plans bought through the federal exchange as well, saying that is what Congress intended.
The cost-sharing subsidies are available to people with incomes from 100 percent to 250 percent of the poverty level ($11,670 to $29,175 a year for an individual). The tax credits are available to people with incomes up to four times the poverty level (up to $46,680 for an individual).
URL: http://www.nytimes.com/2014/11/30/us/politics/suit-on-health-law-puts-focus-on-funding-powers-.html
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September 16, 2016 Friday
Late Edition - Final
California Seeks Insurance for Undocumented Adults
BYLINE: By JENNIFER MEDINA
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 959 words
LOS ANGELES -- In a move that is sure to draw the ire of Republicans, California officials are asking the Obama administration this week to approve a plan that would allow undocumented immigrants to buy health insurance on the state's public exchange.
Officials say that up to 30 percent of the state's two million undocumented adults could be eligible for the program, and that roughly 17,000 people are expected to participate in the first year, if the plan is approved. But the proposal faces serious hurdles in Washington, where it must be approved by the Treasury and the Health and Human Services Departments.
During debates over health care in his first term, and again when Congress considered an immigration overhaul in 2013, President Obama made it clear that health insurance subsidies under the Affordable Care Act would not go to immigrants who are living in the United States illegally. And two provisions of the health care law limit coverage to residents who are here legally. But advocates of California's initiative argue that the plan should be approved under what is known as an ''innovation waiver,'' which allows states to have provisions of the federal law modified, because no federal dollars will be used to fund the program.
''This really represents the next step in health for all,'' said State Senator Ricardo Lara, a Democrat and the author of the bill, who was in Washington this week to garner support for the measure. ''We're simply asking Washington to allow California to once again allow more people to pay into the system. We're reaffirming once again our desire to make affordable preventative care available to everyone and our belief that health care is a human right not a privilege.''
California is the first state to propose such a plan. Immigrants living here illegally represent the largest share of the uninsured in California, and public health officials have been working for years to find ways to provide them with preventive health care. California already offers immigrants more care than other states do. Many counties here provide some basic care through community clinics. And children who are undocumented can now receive Medi-Cal, the state's public health insurance for low-income residents, under a law that took effect this spring.
More than 135,000 children have enrolled so far, but public health officials estimate that the number of those eligible is even higher. Many so-called mixed households, in which some family members are here legally and others are not, have been reluctant to sign up, fearing that they would put themselves at risk for deportation, health officials say.
''We have been saying to people, 'We can sign up your child, but we can't sign you up,''' said Anthony Wright, the executive director of Health Access California, an advocacy group. ''There's a symbolic issue of having a state agency that cannot serve an important part of society, even when they are ready to use their own resources.''
Mr. Wright said that he believed the administration would approve the plan because the state was no longer receiving federal subsidies for the operation of its health insurance exchange, Covered California, which is widely seen as one of the best-run exchanges in the country.
Michael F. Cannon, the director of health policy studies at the Cato Institute and a frequent critic of the health care law, said, ''Obama has already broken promises about the law, and doing this would be another broken promise.'' While undocumented immigrants should have the right to purchase health insurance on the private market, they should not be allowed to do so on public exchanges, Mr. Cannon said, adding: ''This certainly has the potential to become a welfare magnet. You could easily imagine families with high medical expenses moving to California.''
While the proposal will probably meet resistance in Washington, it is widely supported in California, where public health advocates have been laying the groundwork for such a policy for years. Several Republicans in the State Legislature voted to approve the measure in June, and Gov. Jerry Brown signed it into law in July. Covered California then drafted an application for the waiver, which it will submit to the federal government this month. This week, the state's Democratic congressional delegation wrote a letter urging the Obama administration to approve it.
A federal decision on the waiver application could take several months, officials said.
''They have guaranteed there would be no cost to the federal government, so there's no reason not to do this,'' said Representative Zoe Lofgren of San Jose, who is the senior Democrat on the House Judiciary subcommittee on immigration. ''Republicans might rant and rave away, but this is the next logical thing to do if the state wants it.''
Allowing undocumented immigrants to buy health insurance could also save the state money in the long run, Ms. Lofgren and other advocates say, because it would decrease the reliance on emergency rooms.
Chona de Leon, the chief operating officer at Eisner Pediatric and Family Medical Center in Los Angeles, said that many of the uninsured families the clinic saw routinely avoided doctor visits until they wind up in an emergency room.
''They just wait until they are really sick, and it ends up being more expensive for everybody,'' Ms. de Leon said.
Since undocumented children began receiving insurance through Medi-Cal, more families have been coming in for immunizations and well-child visits, she said. But their parents are still reluctant to see a doctor, she said. ''They want to stay healthy and they don't have any way of doing it.''
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URL: http://www.nytimes.com/2016/09/16/us/california-moves-to-allow-undocumented-immigrants-to-buy-insurance.html
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September 26, 2013 Thursday
Late Edition - Final
Tea Party Hero Rankles Senate G.O.P. Colleagues
BYLINE: By JEREMY W. PETERS; Jonathan Martin contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 1113 words
WASHINGTON -- Senator Ted Cruz's crusade to dismantle President Obama's health care law has helped cement his status as an emerging hero of the Tea Party and conservative grass roots. But it is stoking resentment and derision from many other Republicans, including his own Senate colleagues, who see his campaign as impractical, self-interested and potentially damaging to the party's electoral efforts in 2014 and beyond.
The episode has drawn unwanted attention to a deepening rift among Republicans who feel torn between warring elements. As the party looks to take the Senate majority next year and recapture the White House in 2016, the split pits an emerging, younger class of social-media-savvy leaders like Mr. Cruz of Texas, who claim the mantle of a resurgent grass roots, against those who believe their colleagues are recklessly pursuing a strategy that builds up individual political brands at the party's expense.
Some Republicans are beginning to complain more and more that with the help of outside, Tea Party-inspired groups, Mr. Cruz and others like Senators Marco Rubio of Florida and Rand Paul of Kentucky -- both presidential prospects who battled alongside their colleague from Texas in the current health care fight -- are leading conservatives to believe the current fight over cutting money for the health law is winnable when it is not.
''This is not a situation where you dig your heels in and Obamacare gets defunded,'' said Senator Ron Johnson, Republican of Wisconsin, who has one of the most conservative voting records in the Senate. ''I think people are willing to hope that's true. I wish it were true. Trust me, I hope Senator Cruz's oratory convinces five Democratic senators to vote with us. I just don't think that's going to happen.''
Mr. Cruz and others who insist that they can prevail in defunding the health care law, Mr. Johnson added, are misleading voters who are looking to them for leadership that the party has lacked lately. ''They just want anybody who offers them a path, whether it's realistic or not,'' he said.
Senators complained publicly this week that their phone lines had been clogged with calls from voters, many of them misinformed about the true nature of the health care defunding bill now before Congress, as well as the confusing procedural gymnastics taking place on the floor.
''We have people calling into our office every day saying, 'Please support the House bill,' '' said Senator Bob Corker, Republican of Tennessee, referring to the bill that the House passed defunding the Affordable Care Act. ''Well, I do,'' he added, sounding exasperated. ''Do I think this has been a constructive process? Not particularly.''
Mr. Cruz's 21-hour, all-night assault on the Affordable Care Act -- which ended rather anticlimactically on Wednesday after the Senate voted to take up a budget bill that Democrats intend to alter to their liking -- has focused national attention on the 42-year-old agitator, who is only nine months into his first term in the Senate but appears to have greater ambitions. On Tuesday night as he spoke, his political action committee was hosting a $2,500-per-plate fund-raiser in Washington. A television provided a live feed of his speech.
Mr. Cruz's efforts have helped re-energize a sizable contingent of conservatives who felt leaderless and demoralized after Republicans lost seats in Congress and the White House last year.
Groups like FreedomWorks, Heritage Action for America and Tea Party Express have relished picking fights with Republicans like Mr. Corker, whom they dismiss as turncoats. And this week they mobilized as part of a carefully choreographed and mutually beneficial effort to rally conservatives behind Mr. Cruz's cause.
A few days before Mr. Cruz took to the Senate floor on Tuesday, members of his staff began reaching out to some of the country's leading conservative grass-roots groups.
They were cryptic and unspecific, saying only that something big was coming, according to one activist who was contacted, and that they should be prepared to activate their social networks and spread the word. They sprang into action once the senator began talking. They used the Twitter hashtag his staff provided -- #MakeDCListen -- to rally their followers online, and deluged their subscriber lists with millions of e-mails telling people to call their senators and demand they support Mr. Cruz as he pulled his all-nighter.
So far, their message of entrenched Washington Republican interests being at odds with the interests of ordinary Americans has proved to be a powerful one.
''We should continue the fight, that's what the people want,'' Mr. Paul said shortly after Mr. Cruz left the Senate chamber.
Senator Mike Lee, a Utah Republican, said they were acting as a last line of defense for voters who expected Republicans to act. ''A lot of people thought the Supreme Court would act. It didn't,'' he said. ''A lot of people thought Mitt Romney would win, or some other Republican would win, and that would stop it. That didn't happen.''
That message was also a consistent theme of Mr. Cruz's as he spoke into Wednesday morning.
''All of Washington wants to tell you, the citizen: Can't be done,'' he said. ''You cannot win. Your view will not be listened to.''
Conservative Republicans who ordinarily find themselves aligned with Mr. Cruz say they found a certain absurdity in this kind of talk.
''I love their vigor and their spirit,'' said Senator Tom Coburn of Oklahoma, referring to the Republicans who have bucked the party leadership lately. ''But to be told we're not listening by somebody who does not listen is disconcerting.''
Mr. Cruz and his allies in the Republican Party claim a big mantle: the voice of disaffected and restless conservatives, and some say that has upset the established political order.
''Every senator thinks that they're the center of the universe, and now it is literally the case that a very decentralized community has a lot more say,'' said Matt Kibbe, president of FreedomWorks. ''We now have a seat at the table,'' Mr. Kibbe added, taking stock of his detractors in the Senate. Voters, he said, ''can choose their leaders based on who's performing, and that very competitive, bottom-up atmosphere is really what they're complaining about. They're like the dinosaurs seeing the first icebergs floating by.''
No amount of grass-roots energy matters unless the Republican Party wins elections, several senators noted this week. And Mr. Cruz's strategy, they complained, was sure to be a losing one.
''I'm not in the shut-down-the-government crowd,'' said Senator Lamar Alexander, Republican of Tennessee. ''I'm in the take-over-the-government crowd.''
URL: http://www.nytimes.com/2013/09/26/us/politics/cruz-tea-party-hero-rankles-senate-gop-colleagues.html
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The New York Times
February 17, 2015 Tuesday
Late Edition - Final
Health Care Success for Midwest Co-op Proves Its Undoing
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1436 words
RED OAK, Iowa -- A few days after Christmas, Lisa Lovig's doctor called with jarring news. The health insurer covering her cancer treatments had run out of money, and its future was at best uncertain.
''I was terrified,'' said Ms. Lovig, 59, who has pancreatic cancer and relies on her insurance to cover frequent doctor appointments, tests and a litany of expensive drugs. ''I didn't know what was going to happen to me.''
Her insurer, CoOportunity Health, was one of 23 nonprofit cooperatives created under the Affordable Care Act to generate more competition and choice in insurance markets dominated by huge for-profit companies. Many of these newcomers to the industry, seeded with hundreds of millions of dollars in federal loans, struggled to attract customers after the law's online insurance exchanges opened in 2013. But CoOportunity had seemed to flourish, with over 120,000 customers in Iowa and Nebraska -- far more than the 15,000 it had anticipated -- by the end of last year.
Its success apparently helped doom it. CoOportunity's many customers needed more medical care than expected, according to Nick Gerhart, Iowa's insurance commissioner, and it had priced its plans too low. After taking control of the co-op in late December, Mr. Gerhart decided last month that it could not be saved and asked a court to liquidate it. The co-op, he said at the time, faced more than $150 million in liabilities. That left its customers scrambling for new coverage, and providers wondering if millions of dollars in outstanding claims would ever get paid.
More broadly, it raised the question of whether one of the Affordable Care Act's biggest experiments in holding down insurance costs was in trouble beyond Iowa and Nebraska. The co-ops, which the law says must be ''consumer governed'' by boards elected by their customers, have received nearly $2 billion in federal loans, including $145 million that went to CoOportunity. They were initially supposed to receive $6 billion over time, but Congress later slashed the amount and virtually no funds remain.
''Certainly I'm very disheartened right now,'' said Dr. David Carlyle, a family physician in Ames, Iowa, who served on a board that advised the Obama administration on how to set up the cooperatives. ''If you can't have competition, you're going to go back to a world where a large percent of the population is unable to get health insurance.''
A recent analysis by the A. M. Best Company, an insurance rating agency, found that all but one of the co-ops reported financial losses through the third quarter of last year. Some analysts say that it is too early to predict the long-term viability of the co-ops, and that first-year losses were expected. But for now, the losses indicate that many were paying more in insurance claims and other expenses than they were receiving in premiums, a problem that seems to have hurt CoOportunity more than the others.
Perhaps viewing CoOportunity's experience as a cautionary tale, Tennessee's co-op, Community Health Alliance, stopped accepting new customers on Jan. 15, saying it had met its goal for the enrollment period. In a statement at the time, the Tennessee Department of Commerce and Insurance described the move as ''a preventative measure to support the long-term viability of CHA and the protection of Tennessee consumers.''
Even before CoOportunity's failure, Republican critics of the health law had pointed to the co-ops as a risky use of tax dollars. Senator Charles E. Grassley of Iowa last month began an investigation into the federal government's role in CoOportunity's collapse. And on the floor of the House of Representatives recently, Representative Adrian Smith of Nebraska called the co-op's collapse ''one more example of Obamacare's failure.''
CoOportunity executives declined to be interviewed, referring questions to Mr. Gerhart.
Dr. Carlyle said a unique set of circumstances had weakened the co-op. In addition to selling private plans through the exchange, it had agreed to cover new Medicaid enrollees under Iowa's expansion of the program. The co-op pulled out of the Medicaid program in October, saying many of the 9,700 enrollees it covered had significant health needs and were too expensive.
Another problem was that Iowa and Nebraska, with the Obama administration's permission, allowed people to keep old insurance policies that did not meet Affordable Care Act standards through 2016. These people tended to be relatively healthy because before the law took effect, insurers could reject customers who were sick.
That left the two insurers selling plans through Iowa's online exchange, CoOportunity and Coventry Health, to take on a disproportionate number of customers with expensive health problems. Mr. Gerhart said CoOportunity had paid for 21 organ transplants over the last 13 months, for example, and had seen ''higher than anticipated'' claims across the board. The co-op had increased its premium rates by 19 percent for 2015, but ''at the end of the day, they needed capital,'' he said.
Ms. Lovig was among the co-op's most expensive customers. She had been paying more than $1,200 a month for health insurance, but switched as soon as the exchange opened last year because her income was low enough to qualify for financial help under the Affordable Care Act. She and her husband, Barry, chose CoOportunity because of the price -- their out-of-pocket maximum for Ms. Lovig's medical care would be $1,350 -- and what seemed like generous benefits.
Over the year, the couple said, they grew to love the co-op's customer service, too.
''I would say they were the best insurance company we've ever been with,'' Ms. Lovig said.
Mary Stuart, 63, of Omaha, had just signed up with CoOportunity in December when she learned of its financial crisis. Ms. Stuart had marveled at how many doctors and hospitals were in the co-op's network, she said.
''It sounded like an awfully nice deal,'' she said, ''and I guess it was too good of a deal.''
Ms. Lovig's switch to a new insurer, Coventry Health, has not been so smooth. Her new coverage did not start until Feb. 1, meaning she has to pay a new out-of-pocket maximum -- $1,850 -- before the new benefits kick in.
''The timing of it was a real nasty surprise,'' said Mr. Lovig, who sat beside his wife in their living room here with a view of snowy cornfields.
Mr. Gerhart said the state guaranty associations in Iowa and Nebraska would cover outstanding medical claims for CoOportunity customers up to $500,000 a person. He and others, including brokers and enrollment counselors in the two states, had urged co-op customers to choose a new insurer by Sunday, when the latest open enrollment period ended. Roughly three-fourths had switched as of last week, he said.
CoOportunity customers were wondering whom to blame. Mr. Gerhart said it had become clear last summer that the co-op would need more federal loan dollars to stay solvent. He urged the Obama administration to let CoOportunity use federal funds it was not due to receive until later this year as collateral to get a third-party loan, he said, but to no avail.
The administration did lend the co-op $32.7 million in solvency funds in September, on top of $112.6 million it had already received. But it rejected another CoOportunity request, for $50 million, in December, awarding loans to other co-ops instead.
Asked why the co-op did not receive another loan in December, Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, said only, ''At the end of the day, the total funding requests we received from co-ops exceeded the amount available.''
''Any start-up business enters the market with inherent risks,'' Mr. Albright said. ''Not all succeed.''
Dr. Martin Hickey, chairman of the National Alliance of State Health Co-ops, said that based on the third-quarter results posted by the remaining co-ops, ''I honestly, honestly don't expect another co-op to be taken over by a state regulator in 2015.''
Iowans, these days, have only one option on the exchange: Coventry Health. Mr. Gerhart said he was optimistic that more insurers would join before the next enrollment, which starts in October. Ms. Lovig, who was scrambling last week to confirm whether Coventry would cover the nurse who comes twice a month to refill her pain pump, said she hoped that would happen.
''It wouldn't have felt quite so bad if there were half a dozen others to choose from, or even three,'' she said. ''If there's absolutely nobody else doing it, then what you get is probably not going to be as good as it could be.''
URL: http://www.nytimes.com/2015/02/17/us/success-proves-undoing-of-health-insurance-co-op.html
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GRAPHIC: PHOTOS: A CoOportunity Health enrollment bus was sidelined this month outside OCI Insurance in Omaha. Below, Mary Stuart had insurance through CoOportunity for one month and filled only one prescription before it collapsed. ''I guess it was too good of a deal,'' she said. (PHOTOGRAPHS BY ANDREW DICKINSON FOR THE NEW YORK TIMES)
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March 21, 2012 Wednesday
Late Edition - Final
Invitation to a Dialogue: Health Care Rationing
SECTION: Section A; Column 0; Editorial Desk; LETTER; Pg. 22
LENGTH: 338 words
To the Editor:
Starting on Monday, the Supreme Court will consider constitutional challenges to the Affordable Care Act, hearing arguments about Congressional authority to mandate the purchase of health insurance by individuals and threats to states' sovereignty by an expansion of state obligations under Medicaid.
Although not likely to be struck down in its entirety, the law will continue to face stubborn opposition accompanied by lingering charges that ''death panels'' will ration health care.
Many Americans mistakenly believe that Canada and Britain ration care while we do not. In reality, we also ration care, not through waiting lists but through high prices that impede access for those with no or limited insurance.
This inconvenient truth has been twisted into a convenient lie by reform opponents to confuse the public. The specter of rationing has also been invoked by those seeking to repeal the Independent Payment Advisory Board -- a panel that would recommend ways to lower Medicare costs -- so that Congress and special interests may retain firm control over Medicare spending cuts. By delegating responsibility to independent experts, such a board would help depoliticize the existing process.
Lost in the rhetoric is the Affordable Care Act's efforts to reduce rationing through mandatory coverage of preventive services and essential minimum benefits. The act holds promise for more rational allocation and consumption of scarce resources. But first, we must accept the fact that rationing already exists but needs to be made more equitable if we are to achieve better health for our citizens and better value for our health care dollars.
ALAN B. COHEN Boston, March 20, 2012
The writer is a professor of health policy and management at Boston University School of Management and executive director of its Health Policy Institute.
Editors' Note: We invite readers to respond for the Sunday Dialogue. We plan to publish responses, and Professor Cohen's rejoinder, in the Sunday Review. E-mail: letters@nytimes.com
URL: http://www.nytimes.com
LOAD-DATE: March 21, 2012
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February 7, 2014 Friday
Massachusetts Appoints Official and Hires Firm to Fix Exchange Problems
SECTION: US
LENGTH: 739 words
HIGHLIGHT: Gov. Deval Patrick of Massachusetts has appointed an insurance executive to oversee the state’s bungled effort to comply with President Obama’s health care law. The state will also pay a technology firm to help.
BOSTON - Gov. Deval Patrick of Massachusetts has appointed an insurance executive to oversee the state's bungled effort to bring its health exchange in line with the requirements of President Obama's health care law. Mr. Patrick also announced the state will pay a technology firm, Optum, nearly $10 million to help fix the exchange.
"The point is to catch up on the backlog and deliver a system that will give our residents convenience and confidence," said Mr. Patrick at a news conference in Boston on Thursday.
The announcements came the same day as the release of a report that was critical of the state and its principal IT contractor, CGI, for the bumpy rollout last fall of an updated version of the state's health care exchange, an online marketplace for health insurance.
Problems using the exchange meant that many applications had to be processed by hand. Tens of thousands of applicants were either given temporary insurance coverage by the state or had their existing state coverage extended, rather than being enrolled in preferred plans under the new health care law, the Affordable Care Act. Many users have complained that they are unsure of their coverage status because they were not immediately informed about it.
At the end of last year, according to a New York Times analysis, the state was last in the nation in meeting enrollment goals, signing up only 5,428 applicants in private plans. The failure of the website here has been deeply embarrassing both to state officials and proponents of Mr. Obama's law, which in many ways was modeled on Massachusetts' own health care overhaul enacted in 2006. Before the Affordable Care Act took effect, Massachusetts had its own online marketplace, which was running smoothly. But that system had to be updated to comply with the new federal system.
A report commissioned by the state and conducted by an outside technology company, MITRE, identified "significant problems" with CGI's work, saying the IT contractor did not have the expertise to build the site, had lost data, failed to adequately test functions and poorly managed the project. CGI was also a major contractor on the problem-plagued federal health care exchange.
In a statement, CGI said the company "looks forward to continuing our work with Optum to accelerate improvement of the Massachusetts Health Connector. We remain determined to help Massachusetts residents get insured by enrolling in health plans via the Connector, and we fully intend to meet our contractual obligations."
But the report said it was not clear which of the state organizations that worked on the project - the Massachusetts Health Connector, MassHealth (the state's Medicaid program) and the University of Massachusetts Medical Center - was in charge. "There does not appear to be a consistent, unified vision for the system nor clear lines of accountability for implementing the vision," the report said.
Mr. Patrick said that his appointment of Sarah Islen, a Blue Cross Blue Shield executive who worked to implement the 2006 health law here, would improve the state's monitoring of CGI by using a single executive instead of a committee.
"This vendor required and will require a much shorter leash," Mr. Patrick said.
A team of 300 people from Optum, the technology firm that has helped improve the functionality of the federal health exchange, will work with Ms. Islen and CGI to fix the state's website. They will be paid up to $9.8 million over the next month, and the contract may be extended.
"The technology is fixable," said Andy Slavitt, a group executive vice president at Optum. "There's a lot to do and there are more resources needed, but the right activities are underway under Sarah's leadership."
Mr. Patrick said the state would continue working with CGI for now, although they have only paid the company about $15 million of its $68 million contract. "We are only going to pay them if we get a workable system," said Mr. Patrick.
He said that the thought of dismissing CGI had crossed his mind, but the project, with issues of code ownership, was too complex for a clean break with the company.
"We still need CGI for the time being," the governor said.
Federal Data Reveals Variety of Health Care Plans
Employees Without Health Care Coverage Looking to Exchanges
Health Insurers Report High Volume of Queries on Health Care Coverage
Broad Skepticism on Health Care Law
Parties in California Squabble Over Another Website
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(Economix)
June 29, 2012 Friday
Health Care: Solidarity vs. Rugged Individualism
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1075 words
HIGHLIGHT: The debate over the health care mandate has crystallized two approaches to a fundamental question, an individual’s responsibility for the welfare of others, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
For over a year, Americans have debated the implication of the following sentence for the Affordable Care Act: "The Congress shall have power to regulate commerce with foreign nations, and among the several states, and with the Indian tribes." It is known in the vernacular as the commerce clause.
In the coming week, the commentariat will debate what this sequence of letters means among English-speaking people: "p-e-n-a-l-t-y." Because, as an immigrant, I am still struggling with the English language, I shall absent myself from that debate.
Chief Justice John Roberts was the deciding vote on the decision to view the "penalty" to be imposed on Americans who disobey the mandate to have health insurance as a form of tax and, on that basis, declared the mandate in the health care act to be constitutional.
The penalties under the act amount to $695 per year per person (up to a maximum of $2,085 per family), or 2.5 percent of household income, which will be phased in during 2014-16. There are exemptions for individuals or families for whom these penalties would be a financial hardship.
Given these relatively low penalties, one would predict that many younger and healthier Americans will choose to remain uninsured and pay the penalties rather than insure at the community-rated premiums that force them to subsidize the health care of sicker Americans.
While the federal subsidies toward the purchase of private health insurance through the state exchanges will mitigate this effect - by substantially lowering the net premium payable by lower-income people - healthy, higher-income people without the benefit of subsidies are likely to choose just to pay the penalty, knowing that they can avail themselves of community-rated coverage in case of serious illness.
Viewed from that perspective, one could also construe the penalty under the mandate as something approximating the average per-capita actuarial cost that such individuals might impose as a group on hospitals. Such expenses - for what is known as "uncompensated care" - arise when patients without coverage are treated and released with unpaid bills. This supports the notion that the penalty is in effect a tax. (And perhaps one whose revenues should be directed back to such hospitals, as is the case with the Disproportionate Share program for hospitals that serve the poor in large numbers.)
In essence, the struggle over the mandate is merely part of this country's struggle over a fundamental moral question: to what extent must I be my poorer brothers' and sisters' keepers in health care? Americans are far from united in their response to this question.
There are basically three approaches to forcing healthier and wealthier citizens to be their poorer brothers' and sisters' keepers in health care.
1.A tax-financed, government-run social insurance plan (Medicare, Medicaid, Canada, Taiwan, Korea or Japan) or purely socialized medicine (the National Health Service in Britain, or the Veterans Health Administration in the United States).
2.Private health insurance with community-rated premiums and guaranteed issue, with government subsidies toward insurance premiums paid by individuals on a means-tested basis (Germany, Switzerland and the Affordable Care Act of 2010).
3.Private insurance with actuarially fair premiums (based on the health status of individuals), with government subsidies set so that the net out-of-pocket and premium costs borne by the household cannot exceed X percent of household income, where X itself may rise with income.
I am not aware that the latter approach has been tried in practice, perhaps because its administrative cost might be high.
Under any of these approaches, however, many citizens would be forced to subsidize, either with taxes or premiums, the health care of others. Is that fair to libertarians, whose theory of social justice holds the sanctity of justly acquired private property to be the overarching value? They will balk at this coercion as ipso facto "unjust." Libertarians do believe in private charity (ideally not tax-deductible charity) and are probably often charitable, but not through coerced transfers.
So what could be done to let libertarians enjoy the freedom they seek? Here is my idea of an approach.
Let us set up two distinct systems for health care within our nation. Call one the Social Solidarity system and the other the Libertarian system. Ask young people - at age 25 or so - to choose one or the other.
People joining the Social Solidarity system would know that they will be asked to subsidize their less fortunate fellow citizens in health care through taxes or premiums or both. They would also know, however, that the community will take care of them, and they will not go broke, should serious illness befall them.
People choosing the Libertarian system would not have to pay taxes to subsidize other people's health care, and they would pay actuarially fair health insurance premiums - low for healthy people and high for sicker people.
Libertarians, however, would not be allowed to come into the Social Solidarity system, unless they were so pauperized as to qualify for Medicaid. Hospitals would have every right to use tough measures to make them pay their medical bills in full, to prevent freeloading at the expense of others.
Furthermore, care would have to be taken to prohibit the kind of estate planning that now often permits well-to-do individuals to take advantage of Medicaid benefits.
Whenever I offer this proposal in health policy debates, I am told that it is unfair to ask people to make such momentous life-cycle decisions at such a young age.
I thought so, too, until I saw young Marines come home from the battlefield. By joining the Marines - or any branch of the armed forces - young people typically face four years of active duty (and often several more years in the Reserves) in which they risk being maimed or killed.
If we routinely ask 18-year-olds to make such momentous decisions and stick by them, why could we not ask 25-year-olds to choose between a life of social solidarity or rugged individualism?
Health Reform, the Reward to Work and Massachusetts
Older Workers Could Benefit if Companies Drop Insurance
From Physician Glut to Physician Shortage
Awaiting the Supreme Court's Health Care Ruling
Reaction to the Final Hearing on the Health Law
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November 6, 2013 Wednesday
In the Death Spiral We Trust
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 679 words
HIGHLIGHT: Forcing the healthy to buy health insurance may not be an efficient way to run a health insurance marketplace, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
The insurance-market death spiral makes sense in theory, but economists do not really know if, and how often, it is a practical consideration in real-world health insurance markets.
Adverse selection refers to a failure of buyers and sellers to transact because one or the other has additional information about the quality or cost of the product to be traded. A classic example from the 2001 Nobel laureate George Akerlof is the market for quality used automobiles, which in theory cannot exist, because buyers of used cars demand a heavy discount because of the likelihood that a used car they might buy will be defective. In theory, nobody sells a quality used car, because it would have to be priced like a lemon.
The used car market is, in theory, caught in a kind of self-fulfilling prophecy in which only defective cars are traded in the marketplace and are priced accordingly.
The same phenomenon has been used to describe the health insurance market. In theory, absent government intervention, only sick people will buy health insurance, which means that insurers have to charge a lot for the insurance, which means that healthy customers will not buy insurance. This is the supposed "death spiral" for health insurance markets.
The solution to this purported problem is to force everyone - especially the healthy - to buy health insurance. That starts a domino effect of other problems, including the unfortunate side effects of the redistribution, such as discouraging employers from creating and employees from accepting full-time jobs, which authors of the Affordable Care Act found to be necessary in order for everyone to be able to comply with the mandate to buy insurance.
I agree with the 2001 Nobel committee, which explained that the adverse selection idea is "a simple but profound and universal idea, with numerous implications and widespread applications." Still, we don't really know if the side effects of proposed market interventions are more tolerable than the disease itself.
The used automobile market is a good example. A prudent car buyer should be aware that defective cars are out there.
Nonetheless, the market for used cars did not experience a death spiral and today is active and vibrant. Without any government mandate that the owners of quality used cars sell them, the marketplace has devised a number of practices, such as cars leased from the manufacturer, manufacturer warranties and fleet resales, that help buyers expect quality used cars and thereby prevent the death spiral.
Economic theory predicts that all consumers buy actuarially fair insurance - that is, insurance in which each buyer expects to receive as much as he pays - so the mere fact that many people do not have health insurance (especially healthy people, who do not buy because it is too expensive) would seem to prove that the health insurance market is failing.
But the fact is that health insurance companies, like just about any business, have significant capital and labor overhead costs. Insurance premium revenue is needed to pay those costs. Under such conditions, the average consumer must expect to receive less than he pays. Many healthy people may thereby be uninsured for a good reason: the overhead costs are too much to justify whatever feeling of safety that insurance might give them.
The market might be selecting participants in a productive way. Forcing the insured to buy insurance may be a waste of society's resources by adding to the already significant overhead costs.
Without proof that adverse selection outweighs other kinds of selection in health insurance, the death spiral may not be a serious threat, and government actions to prevent it may be unnecessary.
The Midterm Grade for HealthCare.gov
The Power of the Individual Mandate
Medicaid and the Incentive to Work
The Hurdles to Success for the Affordable Care Act
Dealing With Drafting Errors in the Health Care Law
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November 15, 2013 Friday
Programmers Find New Way to Navigate Health Plans
BYLINE: Jessica Bidgood
SECTION: US
LENGTH: 922 words
HIGHLIGHT: Three people who struggled to use HealthCare.gov have founded HealthSherpa, a minimalist website that tells consumers what plans are available in their area.
The stumbling rollout of the federally run online health exchange has frustrated tens of thousands of Americans and sent some looking for alternative sources of information on where they can buy health insurance, and what it will cost them, under the Affordable Care Act.
It took three programmers in their twenties a few days last month to offer up an answer. They repackaged data from HealthCare.gov into a minimalist website, HealthSherpa, that tells consumers what plans are available in their area, based on their ZIP code, plan preference and some basic personal information.
The founders - Michael Wasser, George Kalogeropoulos and Ning Liang - had each struggled to get information about health care options in the online marketplace created by the Affordable Care Act. So they decided to build their own site, intending to offer consumers a simple way to obtain information many had been unable to obtain from federal and some state-run exchanges in their early days.
"Well, this is a cool thing we can get done in two days," said Mr. Wasser, describing the conversation the founders had before they began. "Let's see what we can do."
Using data posted on HealthCare.gov, as well as some they requested from state exchanges, the trio programmed a site that allows users to see a list of available plans in their area, pricing them based on what level of coverage - catastrophic through platinum - the consumer wants. Not all the state exchanges provided data.
Users submit their ages, the size of their family, and whether or not they smoke to get an adjusted price. The website also has a subsidy calculator. While the site offers instructions on how to sign up for a desired plan, it does not allow users to do so on the site; nor can it authenticate users or verify their incomes, as healthcare.gov is intended to do.
"There's one little niche of finding plan data," Mr. Wasser said. He added that the site was by no means intended to replace the federal website. "The whole HealthCare.gov website does many other things."
Mr. Wasser, who is from Seattle, said the website was not making money. His partners are from San Francisco.
Some users have pointed out inaccuracies in the website's results, which the site's creators have generally ascribed to inaccuracies in the data they have been provided. Mr. Wasser said the group has placed requests for more data from HealthCare.gov.
Nevertheless, Mr. Wasser said, the site has amassed more than 1.4 million page views. "How to buy" buttons posted next to each plan, which take users to instructions, have been clicked 152,000 times.
Evidently, Angus King, an independent senator from Maine - a state that did not elect to create its own health exchange - finds the site useful; on Tuesday, he urged his constituents to use it while HealthCare.gov works out its kinks.
"HealthSherpa offers a user-friendly platform to quickly browse through available health insurance plan options, including monthly premium costs, coverage plans, and possible premium subsidies," Mr. King said in a statement on his website. "I recommend that Mainers who are having trouble with HealthCare.gov use HealthSherpa as a temporary alternative until the federal website functions properly."
Shelley A. Francis, an independent health care consultant from Atlanta, turned to HealthSherpa after a protracted wrestling match with the federal site. It had taken three weeks just to create an account on healthcare.gov, she said, adding that navigating the plans once she could see them was "cumbersome."
"It was a nightmare. I don't have time," said Ms. Francis, who used HealthSherpa to narrow her options down to a few providers, which she plans to call in the next few weeks.
"When you want something done around I.T., get the millennials to do it," Ms. Francis added.
Another site, insureks.org, offers plans and prices to Kansas residents. And there are other tools, like the Kaiser Family Foundation's subsidy calculator, that offer information on what families can expect to pay for coverage, but do not offer specific plans.
Sarah J. Dash, a research fellow at the Center on Health Insurance Reforms at Georgetown University, cautioned that the alternative sites could cause some confusion for consumers, because they do not present information in the same way as the federal site or facilitate signing up for specific plans, as the federal site does. Users are given a number to call and a plan to request, or they are advised to click a link that takes them to an insurer's website.
"There's no mechanism for directly enrolling in the exchange with that insurer," said Ms. Dash, who said it could be possible for consumers to accidentally enroll in plans that are not on the exchange, or miss out on tax credits for which they might be eligible.
Ms. Dash also warned that there were some alternative sites that appeared to be actively preying on consumers, by pointing consumers to plans that are not part of the federal insurance marketplace (she did not characterize HealthSherpa as one of these sites).
"There are a bunch of websites, look-alike websites - sometimes they're just kind of linking you to a plan that might be on the nonexchange market," Ms. Dash said. "Someone might sign up for a plan that's not on the exchange inadvertently."
People Who Buy Own Health Policies Face Big Changes
Readers Ask About Subsidies and Other Health Care Law Provisions
At a Miami Health Center, Told to Come Back Another Day
Polls in Overtime on Affordable Care Act
Wisconsin Governor Seeks to Extend Medicaid
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November 21, 2016 Monday
Late Edition - Final
Study Says Many Insured Children Lack Essential Care
BYLINE: By MARC SANTORA
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 21
LENGTH: 1238 words
Margo Solomon has health insurance for herself and her four children.
But actually getting treatment is another matter.
Ms. Solomon, a 35-year-old mother from the Bronx, says she has struggled to find a doctor who accepts her insurance. And with three of her children coping with asthma, and one with more complicated medical problems, locating a specialist is even more challenging. And once in the door, she cannot afford the costs, including for deductibles and medications.
''I feel like I am all alone out here,'' Ms. Solomon said.
She is not alone.
A new study to be released on Monday by the Children's Health Fund, a nonprofit based in New York City that expands access to health care for disadvantaged children, found that one in four children in the United States did not have access to essential health care, though a record number of young people now have health insurance.
The report found that 20.3 million people in the nation under the age of 18 lack ''access to care that meets modern pediatric standards.''
Guidelines issued by the American Academy of Pediatrics say that all children should get health maintenance visits for immunizations and other preventive services; management of acute and chronic medical conditions; access to mental health support and dental care; and have round-the-clock availability of emergency services and timely access to subspecialists.
While Medicaid and many private insurance plans recommend or require that all of those services be provided, under the umbrella of what is known as the medical home, the study found that millions of insured children are not receiving many of the benefits.
There are many children with insurance who cannot get primary care and those who do can often have problems getting specialty care.
As President-elect Donald J. Trump, a Republican, vows to repeal some, if not all, of the Affordable Care Act, which extended health care coverage to an additional 20 million people, the report's authors worry that even more children could have trouble receiving the care they need.
''The fact that more than 20 million children in the U.S. experience insurance and noninsurance barriers to getting comprehensive and timely health care is a challenge that needs to get the highest-priority attention from the new administration,'' said the report's lead author, Dr. Irwin Redlener, president of the nonprofit Children's Health Fund and a professor of pediatrics and health policy and management at Columbia University.
Over the past two decades, the number of children without health insurance has steadily decreased to 3.3 million last year from around 10 million in 1997, according to an analysis of federal data and the federal government's 2015 National Health Interview Survey.
The effort to extend coverage began 50 years ago with the creation of Medicaid, which provides health insurance for the poor. It continued more recently with the Children's Health Insurance Program, which offers low-cost coverage to those who make too much money to qualify for Medicaid and, under the Obama administration, with the Affordable Care Act, offering subsidized coverage and state exchanges.
The study relied on census data and reports by federal agencies like the Centers for Disease Control and Prevention, prominent medical journals, as well as information extrapolated from the fund's clinics and from its national network of programs that provide health care to underserved children across the country.
The findings reveal a system in which getting quality care is often confusing and expensive, with even those who benefit from government programs often becoming deeply frustrated.
For the insured, affordability is still an issue. The report noted that employer-based health insurance premiums for family coverage increased by 73 percent from 2003 to 2013. Employees' contributions to the cost of the premiums climbed by 93 percent over that same period, though the rate of increase slowed after the passage of the Affordable Care Act in 2010. The average deductible for an individual with health insurance was 5 percent of median income in 2013, up from 2 percent in 2003, the report said.
The study also cited a survey that found that 59 percent of pediatricians said they had a hard time collecting patients' shares of deductibles and co-payments from families covered by private high-deductible health plans.
For those with Medicaid, like Ms. Solomon, difficulties in getting care have also grown.
Many clinics and health systems do not accept patients with Medicaid, the study said, because of the low reimbursement rates.
Ms. Solomon's experience is typical.
''When I was pregnant with my last child, I had such a hard time finding prenatal care,'' she said. She called 15 to 20 doctors before finding one who took her insurance. ''I mean, we would call places and they would be like, 'We take it,' but it turned out they didn't,'' she said. ''It was so hard.''
Even something as simple as getting medicine recently for her son's strep throat was not simple. Because of a mix-up with her insurance card, Ms. Solomon had to cover a $20 co-payment for a prescription that should have been free, she said.
The report said experiences like hers were common, both with government programs and some private insurers.
''The impacts of these barriers are significant,'' the report said. ''Parents faced with financial barriers might seek to save money by calling their doctor for advice, rather than seeing that doctor in person; rather than fill expensive prescriptions, a parent might rely on a limited supply of pharmaceutical samples. The medical debt incurred by such costs has been linked to reduced access to care, creating a vicious cycle.''
Perhaps just as significant are the barriers caused by demographics.
Dr. Michael Kappy, a pediatric endocrinologist at Children's Hospital Colorado just outside Denver, has seen the problem firsthand.
Since 1996, he has traveled in Colorado, Montana and Wyoming to reach children in areas that do not have large medical centers or specialists.
''My focus has been strictly speaking to solving the geographic barrier,'' Dr. Kappy said.
The study estimates that around 14 million children live in areas with a shortage of health professionals. More than three million low-income residents in New York live in federally designated shortage areas where, among other criteria, there is less than one primary care doctor for every 3,000 people.
The Affordable Care Act sought to address that problem by expanding the National Health Service Corps, but 65 percent of rural areas still have shortages of health professionals.
Dr. Kappy said one encouraging trend was the use of telemedicine, allowing for patients to be evaluated over the internet, with a local physician assistant aiding with hands-on work. To expand and improve tele-health options, however, the programs need to be properly reimbursed, he said, adding that programs that fund the work of doctors doing outreach to isolated communities were critical.
Dr. Redlener, the study's chief author, warned that repealing the Affordable Care Act without an adequate replacement could result in more than three million children losing their insurance.
''So far,'' Dr. Redlener said, ''none of the proposed replacements will do anything to mitigate what children would potentially lose if the A.C.A. is actually repealed.''
URL: http://www.nytimes.com/2016/11/21/nyregion/many-insured-children-lack-essential-health-care-study-finds.html
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GRAPHIC: PHOTO: Dr. Scott Ikea with Sophie Miller's 9-month-old daughter, Sayeeda Ross, inside the Children's Health Fund's mobile clinic. (PHOTOGRAPH BY HIROKO MASUIKE/THE NEW YORK TIMES)
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November 15, 2014 Saturday
Late Edition - Final
Health Care's Next Test: Getting More to Enroll
BYLINE: By ABBY GOODNOUGH and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1204 words
WASHINGTON -- President Obama's Affordable Care Act will face a substantial new test starting Saturday, when the second enrollment period for buying health insurance under the law begins and proponents embark on a three-month mission to persuade millions more Americans to sign up.
Officials running the revamped online insurance exchanges are promising a smoother enrollment experience this time, after spending heavily on website overhauls and simplifying the application process. Outreach groups are rolling out different strategies, from holding ''pop-up'' enrollment events at shopping malls to bluntly emphasizing the tax penalties that many Americans will face if they fail to get coverage. And the Obama administration is redoubling efforts to sign up young adults, members of minority groups and rural residents, who remain disproportionately uninsured.
But the current enrollment period brings with it complications. It will last only three months -- half the length of the initial one, which ran from October through March. And this time, the insurance exchanges will be juggling two roles: signing up new customers, many of whom may be resistant or hard to reach, and trying to ensure that the seven million people who enrolled for 2014 remain covered.
Sylvia Mathews Burwell, the health and human services secretary, predicted this week that the total number of people insured through the exchanges would grow over the next year to 9.1 million -- an increase of only two million.
''We are not expecting this to be a walk in the park,'' said Anne Filipic, the president of Enroll America, a nonprofit group that works with partners around the country to expand coverage. ''What actually worries me more than anything is how consumers could easily be confused by all the different messages out there: Are you up for renewal? Are you uninsured?''
Still, Ms. Filipic added in a call with reporters Thursday, ''We know what works, we've developed new tools and partnerships to double down on those tactics, and we have the resources to get it done.''
In another wrinkle, the sign-up period is coming on the heels of an election that saw Republicans capture the Senate with renewed calls to repeal -- or at least chip away at -- the Affordable Care Act. And last week, the Supreme Court agreed to hear a challenge to the law that could result in millions of people losing the federal subsidies that help pay for their insurance.
''We need to make sure folks understand that things are moving ahead,'' said Erin Ninehouser, education and outreach director of the Pennsylvania Health Access Network, which enrolls people across much of the state.
Mr. Obama's own role in publicizing the second enrollment period has been low key. A few days before enrollment started last year, he spoke about the law at a Maryland community college, exhorting an audience of 2,000 people to ''tell your friends, tell your classmates, tell your family members'' to sign up.
This year, Mr. Obama is in Asia as open enrollment begins, but he will use his weekly radio address on Saturday to encourage people to sign up. Also, several of his cabinet members have talked about it at stops around the country, and the first lady, Michelle Obama, discussed it in calls Friday with health care providers and young adults.
The online exchanges -- 13 run by individual states as well as the federal marketplace, HealthCare.gov, serving the rest of the nation -- will offer 25 percent more plans this year over all, according to the Obama administration. That means consumers will have more choices, but may also need to spend more time combing through them.
''There's a lot more to explain,'' said M. Ryan Barker, vice president of the Missouri Foundation for Health, a philanthropic group that helps people enroll. The number of insurance companies offering health plans in Missouri has more than doubled, he said, to eight from three.
Most people who have already signed up can have their plans automatically renewed if they take no action. But the Obama administration is encouraging them to shop around because with the new options, they may find a better deal. Many low- and moderate-income people who qualified for federal subsidies to lower their premiums could see the value of those subsidies drop if they keep the same plan. That is because the price of the ''benchmark'' plan, which the subsidies are pegged to, has dropped in many markets.
In deciding whether to re-enroll, the seven million people who already have marketplace coverage will, in effect, be passing judgment on the Affordable Care Act and the options it offers.
''A failure to re-enroll might suggest that with a year's experience, they feel that even their subsidized premiums were not worth the benefit they received,'' said Robert D. Reischauer, a health policy expert and former director of the Congressional Budget Office.
Mr. Reischauer predicted that if this enrollment period went well, the Affordable Care Act would be accepted as a permanent part of the social safety net. But if there are serious problems, he said, ''that will throw more logs on the fire and continue to undermine the public's belief that government can provide complex services in an efficient way."
To make enrollment easier this time, some state marketplaces and insurers are opening stores where people can get help enrolling. Kentucky's marketplace, Kynect, is opening a store at a mall in Lexington where people from all over the state go to shop for Christmas gifts.
Insurance agents and brokers are preparing for a larger role than they had during the first open enrollment period.
''We are communicating with the government on a regular basis,'' said Kenneth J. Statz, an insurance agent in Brecksville, Ohio, ''and we're being considered an important part of the enrollment process.''
Amelia Goldsmith, an enrollment counselor with the Central Virginia Legal Aid Society, said she had already booked a month's worth of appointments with people interested in renewing policies or signing up for the first time. She predicted an extremely busy three months but said she wished the law's future were not still cloudy.
''When people ask me about it,'' she said, ''I don't like not being able to tell them with real certainty that the program will look like this in a couple of years.''
With the tax penalty for not having coverage growing next year to $325 or 2 percent of income, whichever is greater, from $95 or 1 percent of income, enrollment counselors and exchange officials are also planning to use it as a prod more than they did last year.
''We're talking about the penalty a lot more,'' said Cheryl O'Donnell, the Arizona state director for Enroll America. ''What we're saying is that if you don't get coverage this time, your fine is going to double. When we start telling people that, it starts to click a little more for them.''
The Obama administration and state exchanges will also use a tool they did not have last year: testimonials from people who have already gotten insured under the health care law. California's exchange has a statewide advertising campaign, ''I'm In,'' with stories of residents who got insured. New York's exchange will roll out a similar campaign later this month.
URL: http://www.nytimes.com/2014/11/15/us/health-care-act-enrollment.html
LOAD-DATE: November 15, 2014
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GRAPHIC: PHOTO: ''I have a plan to cover L.A.,'' read the sign held by Peter V. Lee, executive director of the California health exchange, at an enrollment event on Friday at City Hall. He is on a nine-day bus tour to persuade residents to sign up for insurance. (PHOTOGRAPH BY MONICA ALMEIDA/THE NEW YORK TIMES)
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The New York Times
January 14, 2014 Tuesday
Late Edition - Final
House and Senate Negotiators Agree on Spending Bill
BYLINE: By JONATHAN WEISMAN; Eric Lipton contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 757 words
WASHINGTON -- House and Senate negotiators reached accord on a trillion-dollar spending plan that will finance the government through September, reversing some cuts to military veterans' pensions that were included in a broader budget agreement last month and defeating efforts to rein in President Obama's health care law.
The hefty bill, filed in the House on Monday night, neutralized almost all of the 134 policy provisions that House Republicans had hoped to include, with negotiators opting for cooperation over confrontation after the 16-day government shutdown in October.
Measures to eliminate the Environmental Protection Agency's ability to regulate greenhouse gases and reverse clean water regulations did not survive the final negotiations.
Republicans also relented on their efforts to strip financing to carry out the Affordable Care Act.
''Obamacare lives another day,'' said Senator Barbara A. Mikulski, Democrat of Maryland, the chairwoman of the Senate Appropriations Committee.
The compromises may be difficult to accept for conservative Republicans, many of whom campaigned in 2010 vowing never to vote on a phone-book-size bill they have not had time to read. And because many of them will balk, the bill will have to have bipartisan support to pass.
Republican and Democratic leaders said they believed they would easily get majorities in the House and Senate, but not without loud protests from both the right and the left.
Republicans do get to point to some conservative victories. The bill would cut $1 billion from the Affordable Care Act's Prevention and Public Health Fund, which Republicans have long targeted, fearing the administration would use it to bolster the law's online insurance exchanges.
The legislation also would impose new requirements for the Internal Revenue Service in reporting its activities to the public and Congress after the agency's scrutiny of Tea Party groups' applications for nonprofit status. The $11.3 billion appropriated for the I.R.S. is down $503 million from the level enacted in 2013.
No money would be given to Vice President Joseph R. Biden Jr.'s high-speed rail projects, or to Mr. Obama's preschool development grants program. And some new regulations supported by liberals would be blocked, including a standard for energy-efficient light bulbs and livestock and poultry controls.
Conservatives also succeeded in prohibiting the Obama administration from transferring inmates to the United States from the military prison in Guantánamo Bay, Cuba.
Otherwise, the bill's winners and losers seem to follow no patterns. The National Institutes of Health, long a congressional favorite, would get $29.9 billion, down $714 million from the level approved by Congress for 2013. Still, the N.I.H. would end up with $1 billion more than it did last year after the across-the-board spending cuts, known as sequestration, severely curtailed its research grants.
In contrast, Head Start, which also suffered last year, would see a $612 million increase, enough to restore the sequestration cuts.
The military budget would total $572.6 billion, $20 billion less than House Republicans wanted. The bill also explicitly prohibits the Postal Service from cutting Saturday mail delivery or closing rural post offices.
Despite the concern over security after the 2012 attack on the United States Mission in Benghazi, Libya, the spending bill earmarks less to embassy security, construction and maintenance than it allotted for fiscal 2013 -- $2.67 billion, down by $224 million.
Specific areas of the country would benefit from provisions. They include $128 million for an expanded border crossing station at San Ysidro, Calif., between San Diego and Tijuana, Mexico. But the final bill allocates less than the $226 million for the project that had been requested by the Obama administration.
The spending bill's costs were set in a deal last month by Representative Paul D. Ryan of Wisconsin and Senator Patty Murray of Washington, leaders of the Budget Committees.
But the final bill restores part of that accord's most controversial spending cut -- a one-percentage-point reduction in cost-of-living adjustments to the pensions of working-age military veterans. Under the bill, that cut will not apply to disabled veterans. Lawmakers in both parties have pledged to eliminate the reduction.
The final plan would raise spending on programs at Congress's annual discretion by $25 billion over the limit originally set by the House, but it cuts spending by $25 billion from the limit approved by the Senate.
URL: http://www.nytimes.com/2014/01/14/us/politics/house-and-senate-negotiators-agree-on-spending-bill.html
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The New York Times
January 30, 2016 Saturday
Late Edition - Final
Last Call to Enroll for '16 Health Insurance
BYLINE: By ANN CARRNS.
Email: yourmoneyadviser@nytimes.com
SECTION: Section B; Column 0; Business/Financial Desk; YOUR MONEY ADVISER; Pg. 5
LENGTH: 634 words
THIS weekend is the final deadline to sign up for health insurance coverage this year under the Affordable Care Act.
If consumers don't sign up at HealthCare.gov by midnight Pacific time on Sunday -- that's 3 a.m. Monday on the East Coast -- they must wait until the fall, and their health coverage won't start until 2017. (States that run their own insurance marketplaces have similar deadlines.)
In December, HealthCare.gov extended the deadline (for coverage starting Jan. 1) by two days, because of a last-minute surge in enrollments. But there's no indication that will happen again.
''We'd encourage consumers not to rely on a possible extension, but to plan for the deadline,'' said Cheryl Fish-Parcham, private insurance program director at Families USA, a consumer advocacy group.
If consumers enroll by the Sunday deadline, their health coverage will start March 1.
Those who miss the deadline can sign up later for 2016 coverage only if they have a qualifying circumstance, like getting married, having a baby or losing job-based health coverage.
Last year, taxpayers who missed the open enrollment deadline were allowed to sign up later if, when filing their income tax return, they were surprised to learn that they would have to pay a penalty for not having coverage. But there will be no special ''tax time'' enrollment option this year, the government has said.
In addition, the government may start doing more to verify that consumers are truly eligible to sign up during special enrollment periods. Insurers have complained that the government has been too lenient in allowing consumers to sign up after open enrollment, making it difficult to manage plan costs.
It's not clear what documentation may be required, said Sabrina Corlette, a health care researcher at Georgetown University. But after Sunday, she said, ''People should not be surprised if they start getting asked to provide some form of proof'' that they qualify.
As the Sunday deadline approaches, consumers can get help by phone 24 hours a day by calling 800-318-2596. Or they can find in-person help in many areas over the weekend. To find a site nearby, visit LocalHelp.HealthCare.gov. Some locations may require an appointment, but others will accept walk-ins.
''We have been busy,'' said Pranay Rana, a consumer education specialist in Atlanta with the nonprofit group Georgians for a Healthy Future. Enrollment help will be available over the weekend at a variety of locations, he said, including community centers and churches.
Here are some questions and answers about coverage:
â- What is the penalty for not having coverage in 2016?
The penalty for not having coverage this year is $695 per adult, or 2.5 percent of household income, whichever is greater. (That's up from $325, or 2 percent of household income, for 2015.) If you sign up for coverage by Sunday and keep it for the rest of 2016, you won't have to pay a penalty when you file your taxes next year. The law allows you to have short-term gaps in coverage without paying a penalty.
â- If I was automatically re-enrolled in the plan I had in 2015, can I still change my plan for this year?
Yes. You can change your plan selection if you act by the Sunday deadline.
â- If I had marketplace coverage last year, do I need to do anything special when filing my taxes?
If you had coverage through the Affordable Care Act in 2015, you'll be mailed a statement with information you'll need to file your income tax return. HealthCare.gov advises that you wait to file your return until you receive the form, which should arrive by early February.
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URL: http://www.nytimes.com/2016/01/30/your-money/last-call-to-enroll-for-2016-insurance-under-the-affordable-care-act.html
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GRAPHIC: PHOTO: Sunday is the deadline to sign up for coverage under the Affordable Care Act. (PHOTOGRAPH BY JIM WILSON/THE NEW YORK TIMES)
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The New York Times
October 7, 2015 Wednesday
Late Edition - Final
Clinton's Health Care Proposals, Focused on Cost, Go Well Beyond Obama's
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 1401 words
WASHINGTON -- Hillary Rodham Clinton, as she offered up a sheaf of new health care proposals, said she was ''building on the Affordable Care Act.'' But lurking in those proposals was a veiled criticism of President Obama's signature domestic achievement: For many families, the Affordable Care Act has not made health care affordable.
Mr. Obama has spent five years minimizing cost issues still confronting many health care consumers. Mrs. Clinton is taking those on without apologies. She would go beyond the president's 2010 law, capping a patient's share of the bill for doctor visits and prescription drugs. She would repeal the law's planned tax on high-cost employer-sponsored insurance -- a tax the White House says is needed to constrain the growth of health spending.
And Mrs. Clinton, like Bill Clinton when he was president, appears to be more willing to confront insurers and drug makers over high prices. She said she would seek ''authority to block or modify unreasonable health insurance rate increases'' and stop ''excessive profiteering'' by drug companies.
Those comments echoed her criticism of the industry 22 years ago. As chief architect of her husband's plan to remake the nation's health care system in 1993, she accused insurance and pharmaceutical companies of ''price gouging'' and ''unconscionable profiteering.''
''Health care is one of highest-ranking issues she hears about over and over,'' said Chris Jennings, an informal adviser to Mrs. Clinton who worked on health issues in the Clinton White House.
Mrs. Clinton's recent comments surprised and irked Obama administration officials. A White House spokeswoman said that, to her knowledge, the Clinton campaign had not consulted the administration.
The White House press office issued a statement describing the tax on high-cost health plans -- the so-called Cadillac tax -- as ''a key part'' of Mr. Obama's health care law. Repealing it ''would hurt our economy by increasing the deficit, raising health care cost growth and cutting workers' paychecks,'' the White House said. It would also blow an $87 billion hole in the government's revenue stream over eight years, according to the Congressional Budget Office.
Even as she proposed changes in the health law, Mrs. Clinton said it was working, and she promised to fight Republican efforts to dismantle it. Republicans said she was trying to have it both ways, embracing popular parts of the law while rejecting those that are unpopular.
Mrs. Clinton's health policy proposals were calculated to appeal to Democratic voters and labor unions who might be tempted to support Senator Bernie Sanders of Vermont, her main rival for the Democratic presidential nomination. Many unions say the Cadillac tax, scheduled to take effect in 2018, will hurt their members, including schoolteachers and factory workers who gave up higher wages to secure generous health benefits.
But her aggressive approach is nothing new. The health care plan she drafted for her husband, as presented to Congress in 1993, had the same goals as Mr. Obama's health law, but it took a more aggressive regulatory approach. The government would have set lower limits on out-of-pocket costs and provided more generous subsidies to many consumers and employers. A new agency, the National Health Board, would have set a health budget for the nation and would have regulated most private insurance premiums. And ''regional health alliances'' would have been responsible for collecting premiums and could have set fee schedules for doctors.
Mrs. Clinton revealed her opposition to the Cadillac tax five days after a dozen senators introduced legislation to repeal it. Among the senators were Mr. Sanders, who has support from many rank-and-file union members, and Chuck Schumer of New York, the No. 3 Senate Democrat, who is expected to take over as Democratic leader with the retirement of Senator Harry Reid of Nevada next year.
Mr. Obama has long boasted about the law's provisions that hold down consumer costs. The law imposes limits on out-of-pocket costs and requires insurers to cover preventive services, like vaccinations and cancer screenings, at no cost to consumers.
And the big rate increases sought by some health insurance companies for 2016 are less significant than they appear, administration officials maintain, because most people buying insurance through the Affordable Care Act's public exchanges receive federal subsidies that cover most of the premium. They do not need to worry about the ''list prices,'' officials said, and if they do, they can switch to less expensive plans.
But Mrs. Clinton said that many families still struggled with medical costs. She wants Congress to give them financial assistance: tax credits up to $2,500 a year for an individual and $5,000 for a family if out-of-pocket health costs exceed 5 percent of income.
Each insurer sets its own limits on out-of-pocket costs, up to a federally imposed maximum. The limits this year cannot be more than $6,600 for an individual plan and $13,200 for a family plan.
The Affordable Care Act requires health insurers to disclose the costs to consumers of specific medical services, but the Obama administration has yet to enforce that requirement, disappointing consumer advocates who say the data would be useful to patients.
Mrs. Clinton said she would ''vigorously enforce'' these provisions and broaden them so consumers could make more informed choices about coverage and save money.
The Obama administration does post information about the benefits and costs of different health plans, but making comparisons can be difficult because the plans do not use a standard definition of deductible -- the amount that consumers owe before their insurance begins to pay.
Mrs. Clinton would go further than the law's guarantee of free preventive health services and would require insurers and employers to cover three ''sick visits'' a year without charging a deductible.
The White House pointed out that one of Mrs. Clinton's proposals -- to let Medicare negotiate prices for high-cost drugs and biotech medicines -- was in Mr. Obama's budget in February.
Again, Mrs. Clinton would go further. She would limit consumers' out-of-pocket costs for prescription drugs to $250 a month, or $3,000 a year. She would eliminate tax breaks for drug advertising aimed at consumers. And she would put pressure on pharmaceutical companies to spend more of their revenue on research and development.
She is also proposing measures to protect consumers against ''surprise medical bills.'' Health plans often have networks of preferred doctors and hospitals. Even when patients use one of the preferred hospitals, they sometimes receive tens of thousands of dollars in unexpected bills from anesthesiologists, surgeons and other doctors who were not in the network.
Under her proposal, Mrs. Clinton said, consumers would not have to pay those extra charges for care at hospitals in their health plan's network.
In a series of reports in recent years, the Obama administration has cited data to show that health costs were growing at the slowest rate in decades. But that overall trend may stem in part from costs landing directly on patients, causing them not to seek needed care, experts said.
''One way to lower premiums is to increase deductibles, shifting costs back to consumers,'' Mr. Jennings said. ''Mrs. Clinton worries that high deductibles lead to the underuse of necessary medical care.''
A recent study by the Commonwealth Fund, a foundation that specializes in health policy, said that ''the growing use and size of deductibles in both employer and marketplace plans as a means to lower premiums threatens to undermine the gains Americans have made in coverage since 2014.''
Neera Tanden, president of the Center for American Progress and a longtime confidante of Mrs. Clinton, said the health care law poses a challenge for Democrats. The law, she said, has expanded coverage and slowed the growth of national health spending, both major achievements.
But, Ms. Tanden said, ''consumers feel their costs have risen'' because wages are stagnant and many employers have required workers to shoulder a greater share of their medical expenses.
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URL: http://www.nytimes.com/2015/10/07/us/politics/hillary-clintons-proposed-changes-to-health-law-zero-in-on-affordability.html
LOAD-DATE: October 7, 2015
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GRAPHIC: PHOTO: Hillary Rodham Clinton in Manchester, N.H., on Monday. She says she would cap patient costs and move to block ''profiteering.'' (PHOTOGRAPH BY IAN THOMAS JANSEN-LONNQUIST FOR THE NEW YORK TIMES)
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The New York Times
December 7, 2013 Saturday
Late Edition - Final
Obama Recalls an Aide to Guide Health Care Law
BYLINE: By JACKIE CALMES
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 1033 words
WASHINGTON -- As the Obama administration continues the aggressive public defense of the Affordable Care Act it began this week, the president will get some help from his former chief congressional lobbyist, Phil Schiliro, who is returning temporarily to the White House almost exactly two years after he left.
Mr. Schiliro's job, which is expected to last a few months, is to help protect the health care law from legislative attacks by repeal-minded Republicans in Congress, and to quiet dissent from politically vulnerable Democrats seeking to distance themselves from the law and the president ahead of the midterm congressional elections.
He will also be responsible for coordinating with Congress and executive agencies as the administration continues to put the law's wide-ranging policies into effect, and helping to develop communications and legislative strategies on any potential changes to the law, according to people familiar with the assignment.
''We are focused like a laser on reducing health care costs and implementing the Affordable Care Act, and Phil will be vital to ensuring it is done right,'' said the White House chief of staff, Denis R. McDonough. ''Phil has the expertise, the wisdom, and the relationships to tackle any project -- large or small. We are blessed to have him back.''
Mr. McDonough, who has spent much of the past two months directing the administration's response to the problem-plagued rollout of the health care law, is probably as thankful as anyone for Mr. Schiliro's return, which is expected next week. Some White House officials have said the troubled program has consumed too much of Mr. McDonough's time when his responsibilities are much broader.
Mr. Schiliro's policy task essentially is parallel to the more technical job that Mr. Obama gave to Jeffrey D. Zients, another former administration troubleshooter who was brought in last month to oversee the repair of the federal insurance website, which suffered widespread failures as soon as it went live on Oct. 1.
News of Mr. Schiliro's return comes as the White House intensifies a political counteroffensive -- led by Mr. Obama -- to promote the law's benefits amid improvements in the website and increased enrollments. He will lead a behind-the-scenes effort complementing the public relations campaign.
Perhaps only the president himself could have enticed Mr. Schiliro, 57, back into government after he fled Washington for a new life with his family in New Mexico. After more than three decades working for congressional Democrats and then Mr. Obama, Mr. Schiliro had done what so many political people in the capital only talk about doing -- he quit his job, moved to a long-dreamed-of place and created a different life. With his wife and young daughter, he moved 2,000 miles away and built a business consulting for nonprofit groups on public health, childhood poverty and environmental issues.
''We moved to New Mexico to go in a new direction, but this is important to the president,'' Mr. Schiliro said in an email confirming his agreement to take on the special assignment. ''A law that guarantees coverage to millions of Americans, improves quality, and saves hundreds of billions of dollars is worth fighting for. I hope to help with that effort.''
When Mr. Schiliro was leaving, Mr. Obama said, ''The White House will not be the same without Phil.'' Mr. Schiliro was one of only two in the White House whom Mr. Obama honored with a pen from among the set that the president used to sign the Affordable Care Act into law in 2010.
As Mr. Obama's chief liaison to Congress in his first two years, starting in November 2008 with the postelection presidential transition, Mr. Schiliro helped shepherd one of the heaviest legislative agendas in any Congress, reflecting both the new president's ambitions and the circumstances of a global recession and financial crisis.
Among the other laws he helped to pass in what was then a Democratic-controlled Congress were a two-year, $800 billion economic-stimulus package and the Dodd-Frank law overhauling regulation of the banking system. The president has also credited Mr. Schiliro with helping to win Senate ratification of an arms-control treaty with Russia and confirmation of two Supreme Court justices. But the health care law was Mr. Schiliro's labor of love.
More than three years later, however, problems with the state and federal insurance marketplaces, delays in some of the law's major provisions and Republican attacks have undermined public support for it. A few moderate Republicans -- arguing that repeal is impossible so long as Mr. Obama is president, and even then would be unlikely as more Americans benefit from the law -- have called instead for addressing problems as they become evident. Some Democrats, including a few senators in tough re-election contests, also have argued for policy fixes.
''I've never seen a law of the complexity of this one not be followed by legislation to correct some problems,'' said Representative Henry A. Waxman, Democrat of California. ''But that can't even be contemplated because the only thing that Republicans want to talk about is repealing it.''
For a White House often criticized for not engaging enough with lawmakers of either party, Mr. Schiliro brings relationships among House and Senate members developed over decades. For more than a quarter-century, he worked for Mr. Waxman, including as his chief of staff and as his Democratic staff director on the House Oversight and Government Reform Committee. In 2004, he was a senior adviser to Senator Tom Daschle, then the minority leader, and other Senate Democratic leaders.
The White House is counting on his return to help reassure fretful Democrats that the administration has a handle on carrying out the new law, after what Mr. Obama has called the unforced error of the website dysfunction.
''Phil is an excellent choice,'' Mr. Waxman said. He added: ''People at the White House and the Department of Health and Human Services get so bogged down on so many other things, and they're stretched so thin, especially with the troubles in the rollout of the website, Phil will be able to take on things that others might not see.''
URL: http://www.nytimes.com/2013/12/07/us/politics/obama-recalls-an-aide-to-guide-health-care-law.html
LOAD-DATE: December 7, 2013
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The New York Times
May 22, 2015 Friday
Late Edition - Final
$1.6 Billion Is Offered to Hospitals in Florida
BYLINE: By LIZETTE ALVAREZ
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 708 words
MIAMI -- The federal government opened the door on Thursday to a compromise that could ease Florida's budget impasse, rooted in a disagreement over Medicaid expansion and the cost of caring for the uninsured.
In a letter to Florida's top health care official, the Obama administration said that it could authorize $1 billion for the 2015 fiscal year and $600 million for the 2016 fiscal year to reimburse hospitals for treating patients who do not have insurance. The cost would be shared by the state and federal governments. The $1 billion offer is less than half of what the state requested for this year for the Low-Income Pool program, which is set to expire June 30.
Before it could receive the money, the state would have to resubmit its proposal to reflect the lower amounts, and then final federal approval would need to be granted. The administration said it had made the announcement because it recognized that Florida needed guidance to complete its budget.
Payments to hospitals for uncompensated care have caused deep divisions between the Florida House and Senate, which are both controlled by Republicans. The Senate is pushing for a version of private-sector Medicaid expansion. But Gov. Rick Scott, a Republican who announced his support for Medicaid expansion in 2013 despite his opposition to the Affordable Care Act, reversed his position this year and, along with the Florida House, now opposes expansion.
The gaping $4 billion discrepancy between what the House and Senate have proposed, and the question of how best to resolve it, prompted the House and Senate to end the legislative session without approving a budget. The House ended its session early. The lawmakers will convene in a special session on June 1.
Mr. Scott suggested recently that the disagreement could result in a government shutdown.
''I believe the clear indication before the special session is Florida will receive a significant level of LIP funds, which will help us in our effort to finish the budget by the July 1 deadline,'' the House speaker, Steve Crisafulli, a Republican, said, using the acronym for the Low-Income Pool program.
Last month, Mr. Scott sued the Obama administration, accusing it of trying to ''coerce'' Florida to expand Medicaid under the Affordable Care Act by withholding the money for hospitals. But the administration said the two programs were not linked. Officials said Florida had been told in 2012 and again in 2014 that the hospital funding program would expire in 2015 and that the state needed to pursue an alternative.
The $1.6 billion offered for the next two fiscal years would serve as a stopgap, helping Florida transition by 2017 to comprehensive coverage for people who still do not have insurance. An estimated 800,000 Floridians earn too much to qualify for Medicaid and too little to qualify for subsidies for insurance in the federal marketplace.
The administration reiterated that expanding Medicaid would funnel $2.1 billion in federal money to Florida hospitals. But Florida has not approved a plan to expand Medicaid or provide coverage to the uninsured.
The letter on Thursday did not promise the money, an Obama administration official said. Rather, it advised Florida that a preliminary review had concluded that $1 billion this year and $600 million next year would be appropriate levels of funding.
''Our preliminary view is that 2015 and 2016 should serve as a transition year,'' said Vikki Wachino, director of the federal Centers for Medicare and Medicaid Services. She added that the initial $1 billion would help ''to create stability for providers while the state creates alternative financing arrangements.''
Ms. Wachino said the Senate proposal needed more work, in part because it did not do enough to increase provider rates and shift away from old formulas to compensate providers for treating low-income patients without insurance.
The Senate president, Andy Gardiner, who championed a plan to expand coverage to more low-income Floridians, said the letter showed that Florida must come up with a comprehensive plan for the uninsured.
''It remains clear that a sustainable long-term solution is needed,'' Mr. Gardiner, a Republican, said in a memo to his fellow senators.
URL: http://www.nytimes.com/2015/05/22/us/politics/florida-hospitals-get-1-6-billion-offer-from-obama-administration.html
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The New York Times
August 21, 2013 Wednesday
Late Edition - Final
Health Care Costs Climb Moderately, Survey Says
BYLINE: By ANDREW POLLACK
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1
LENGTH: 826 words
Premiums for employer-provided health insurance have increased by relatively modest amounts this year, according to a new survey, a further sign that once-torrid health care inflation has abated for now.
The average annual premium for a family rose 4 percent in 2013, to $16,351, according to the survey results released Tuesday by the Kaiser Family Foundation. Annual premiums for individual policies purchased through an employer rose 5 percent, to $5,884.
The 4 percent increase for a family is relatively tame, at least compared with the roughly 10 percent annual increases experienced a decade ago. But it is still a far bigger rise than 1.8 percent increase in wages and the 1.1 percent rate of inflation in the last year, the foundation said.
''If you are comparing it to 10 years ago in health care, it seems modest,'' said Helen B. Darling, chief executive of the National Business Group on Health, which represents large employers. ''If you compare it to the economy and what inflation is doing, I don't think it's modest at all.''
The data also suggest that the new health care law is not leading, at least so far, to a rapid escalation of insurance costs.
''The critics will have a much harder time blaming big premium increases in employer insurance on Obamacare this year, because there aren't any big premium increases,'' Drew Altman, chief executive of the Kaiser foundation, said in a telephone news conference Tuesday.
Conversely, however, it is not clear if the Affordable Care Act, as the law is formally known, has contributed to the moderating of premium increases, Kaiser researchers said.
Premiums have been held in check partly by increasing out-of-pocket costs that workers pay through co-payments and deductibles.
The survey found that 78 percent of covered workers have a general deductible, up from 72 percent in 2012. About 38 percent of covered workers now face a deductible of at least $1,000. At companies with fewer than 200 employees, 58 percent of covered workers have a deductible that large, with 31 percent having a deductible of at least $2,000, up from 12 percent in 2008.
''It's part of what I see as a quiet revolution in health insurance, from more comprehensive to less comprehensive, with higher deductibles,'' said Dr. Altman, who added that that should appeal to conservatives. ''The vision of insurance that they've always favored, with more skin in the game, is the one that's coming to dominate in the marketplace.''
While out-of-pocket costs are going up, the proportion of total premiums paid by workers out of their paychecks did not change in the last year, Kaiser said. On average workers paid $4,565, or about 28 percent, of the average family premium and $999, or 17 percent, of the average individual premium.
The survey results showed that employers are not dropping health benefits and forcing their employees to seek coverage on the new exchanges being set up under the Affordable Care Act.
About 57 percent of all companies are offering health benefits this year compared with 61 percent last year, a difference that was not statistically significant. Among companies with three to nine workers, 45 percent offered some benefits compared with 50 percent in 2012, a decline that also was not statistically significant.
The 4 percent increase in family premiums in 2013 was similar to the increase in 2012 and in most of the last several years. But since 1999, premiums have nearly tripled while wages have gone up only 50 percent and consumer prices only 40 percent.
The slower increase in premiums appears to reflect slower growth of health care spending in general that is partly explained by people forgoing visits to doctors and medical procedures because of the bad economy.
There is a debate about whether the Affordable Care Act is contributing to the moderation. It has not gone into effect fully yet, but some health care providers might already be cutting costs in anticipation. At the same time, employers have been asking workers to pay higher deductibles and be more selective
''My general sense is it's too early to take what's happening with health care spending, whether it's for good or bad, and assign it to the A.C.A.,'' said Martin S. Gaynor, a professor of economics and health policy at Carnegie Mellon University.
Kaiser conducted the survey of more than 2,000 companies of various sizes, with the Health Research and Educational Trust, which is affiliated with the American Hospital Association.
A separate survey that will be released Wednesday, commissioned by the Commonwealth Fund, has found that an estimated 7.8 million young adults are insured because of the Affordable Care Act provision allowing them to be covered by their parents' plan.
The survey found that, contrary to common perceptions, many young adults, age 19 to 29, are interested in health insurance. But it also found that only 27 percent were aware of the new state health insurance marketplaces that are starting Oct. 1.
URL: http://www.nytimes.com/2013/08/21/business/survey-finds-modest-rise-in-health-insurance-premiums.html
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July 25, 2015 Saturday
Late Edition - Final
Anthem Strikes Cigna Deal as Insurers Seek to Merge
BYLINE: By MICHAEL J. de la MERCED and CHAD BRAY; Robert Pear contributed reporting.
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1
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Two more of the nation's biggest health insurers are moving to merge, raising the possibility of a potential fight with antitrust regulators.
Anthem said on Friday that it had agreed to buy Cigna for $48.3 billion, finally striking a deal after a nearly yearlong pursuit. Buying its rival, Anthem intends to create a new giant in the sector, gaining greater scale and considerably cutting costs.
But the proposed transaction, coming three weeks after Aetna said it would to buy Humana for $37 billion, could shrink the number of major companies in the health insurance industry from five to just three. And that could mean fewer options and higher rates for consumers and the employers that provide health insurance.
The question now is whether government officials will allow that level of consolidation to pass. The United States Department of Justice and the Federal Trade Commission have become more assertive about challenging merger combinations in recent years, analysts and industry experts have noted.
''Economic evidence shows that with fewer competitors, insurance premiums tend to be higher,'' said Thomas L. Greaney, an expert on health and antitrust law at Saint Louis University. ''Less competition among insurers produces higher prices for consumers.''
The Obama administration has not always approved of consolidations that create industry behemoths. For example, after much consumer and industry outcry, the long-planned $45 billion merger of Comcast and Time Warner Cable was called off after regulators indicated they would block the deal.
Health insurers, however, may be viewed differently. The industry players have been eager to combine, hoping to take advantage of growing opportunities, particularly with the recent government push to provide health insurance to those who have not traditionally had it. Insurers' operations have been bolstered by the Obama administration's health care overhaul, which has increased their revenue, even as many start-ups have entered the sector.
The Obama administration says that 16 million uninsured people have gained coverage since major provisions of the Affordable Care Act took effect several years ago.
The recent drive for deals among insurers is also spurred on by the Supreme Court upholding the portion of the Affordable Care Act that subsidizes consumers who buy policies through the government's online marketplace. The act and its introduction of health insurance exchanges, however, have also introduced greater transparency in pricing, weighing down profit margins. Less generous funding of government plans has added additional pressure.
These reasons have led the top health insurers to scramble for partners to merge with in order to cut costs. Their sense of urgency also stems from concerns that government regulators will at some point block potential combinations as anticompetitive.
Anthem began pursuing Cigna last August, negotiating privately for months. But the talks hit a roadblock over a number of issues like who would run the combined company, and Anthem took its campaign public last month to put additional pressure on its target.
Together, Anthem, which runs Blue Cross plans in 14 states, and Cigna, which offers insurance plans through employers, would have around $115 billion in revenue. Cigna also has 24 million behavioral health customers, nearly 14 million dental care members, eight million pharmacy benefit plan members and 1.5 million Medicare Part D pharmacy customers.
The deal, by Anthem's estimate, will lead to nearly $2 billion in annual cost savings.
''We believe that this transaction will allow us to enhance our competitive position and be better positioned to apply the insights and access of a broad network and dedicated local presence to the health care challenges of the increasingly diverse markets, membership and communities we serve,'' Joseph R. Swedish, Anthem's chief executive, said in a news release.
Unlike Cigna, Anthem had been a major presence on the public insurance marketplace created by the federal health care law.
Regulators on the federal and state levels are likely to scrutinize how the combination of Anthem and Cigna will affect local markets and whether any proposed divestitures will be enough to dilute the market power of the remaining firms.
''These mergers should be challenged by the Justice Department,'' said David A. Balto, a former policy director of the Federal Trade Commission who has publicly opposed such deals. ''To go and approve these mergers would be to effectively reverse some of the gains of the Affordable Care Act.''
Some doctors fear that the combination of Anthem and Cigna will put them at a disadvantage in negotiations over payment and coverage for the services that they provide.
''The lack of a competitive health insurance market allows the few remaining companies to exploit their market power, dictate premium increases and pursue corporate policies that are contrary to patient interests,'' said Dr. Steven J. Stack, the president of the American Medical Association.
Not all share that worry. Peter V. Lee, the executive director of California's health benefit exchange, said the mergers of health plans could counterbalance the growing power of health care providers.
''I am far more concerned about the consolidation of hospital and physician groups than the consolidation of health plans,'' Mr. Lee said.
Anthem and Cigna officials say that they believe they can meet the demands of government officials.
''Quite frankly, from a governmental perspective, we think we will continue to deliver, if not accelerate, best-in-class solutions for Medicare, Medicaid and the dual-eligible population,'' Mr. Swedish of Anthem told analysts in a conference call on Friday. ''I think that will stand on its own merit and be a significant uplift in terms of how regulators view us.''
Under the terms of the deal, Anthem said it would pay $103.40 a share in cash and 0.5152 of a share in Anthem stock, or $188 a share. That represents a 38.4 percent premium to Cigna's closing price on May 28, before news of Anthem's interest emerged.
Based on Cigna's most recent disclosures, the deal would value its equity at $48.3 million. Including the assumption of debt, Anthem said the deal would value Cigna at $54.2 billion.
Mr. Swedish is expected to run the combined company, while his counterpart at Cigna, David Cordani, will serve as president and chief operating officer.
The transaction is subject to shareholder and regulatory approval. If it passes these and other tests, the deal is projected to close in the second half of 2016.
URL: http://www.nytimes.com/2015/07/25/business/dealbook/anthem-cigna-health-insurance-deal.html
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October 13, 2014 Monday
McConnell and Grimes Debate: United in Vagueness
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 521 words
HIGHLIGHT: Both candidates reached absurd heights in the art of weasel-wording.
LEXINGTON, Ky. - Political campaigns aren't generally associated with specificity or truth-telling and political debates are no different. But at Monday night's debate in Lexington, both Senator Mitch McConnell and his Democratic challenger, Alison Lundergan Grimes, the Kentucky Secretary of State, reached absurd heights in the art of weasel-wording.
Ms. Grimes knew the question was coming, since she's fielded it several times in the last few days. The host of the debate, Bill Goodman, asked Ms. Grimes for whom she'd voted in the 2012 presidential election. I'll take a wild guess here that Ms. Grimes, a Democrat who was a member of the Kentucky delegation to the Democratic National Convention two years ago, went for the Democrat: Barack Obama.But she refused to say - because she's petrified of being associated with the president, who is deeply unpopular in Kentucky. Instead, she took umbrage at the question on the grounds that the Kentucky constitution guarantees ballot box secrecy. She actually made the preposterous claim that by ducking the question she was standing on constitutional principle.
Mr. McConnell then made her look foolish by freely sharing his votes in the 2008 and 2012 presidential contests, as well as in the 2010 Senate race, when he voted for Trey Grayson, who lost to Rand Paul, the Tea Party darling.
Mr. McConnell, who's been in Washington long enough -30 years - to know how to speak without communicating any information, had plenty of opportunity to show off his considerable obfuscation skills.
Is the minimum wage a living wage, Mr. Goodman asked Mr. McConnell. "It's an entry-level wage," said Mr. McConnell, hardly an answer.
Is climate change real? Before he could plead that he was "not a scientist," Mr. Goodman pointed out that although the senator was not an economist, he was willing to share his opinions on the economy. In a tight spot, Mr. McConnell said: "There are a bunch of scientists who feel there is a problem and maybe we can do something about it."
Lest he be accused of siding with environmentalists, he added the caveat that scientists in the 1970s thought we were moving toward an ice age, and closed by declaring that his job, as United States Senator from Kentucky, was to fight for coal jobs in the state.
Mr. McConnell approached Ms. Grimes's "ballot box secrecy"-level of absurdity when Mr. Goodman asked him if "Obamacare and Kynect" had been "a boon or bane" for the state. The difficulty for Mr. McConnell is that the Affordable Care Act is politically toxic in Kentucky, while Kynect - which is the state's health insurance program created under the Affordable Care Act - is a runaway success.
Mr. McConnell's attempt to separate the two made no sense. The Affordable Care Act should be "pulled out root and branch." As for Kynect, that's just "a website. It was paid for by a grant. The website can continue."
Seeking clarity, Mr. Goodman asked if Mr. McConnell would support the continuation of Kynect. "Yeah, I think it's fine to have a website, yeah," said the senator.
That's like saying that Google should cease to exist but that Google.com should live on.
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January 24, 2017 Tuesday
Late Edition - Final
Angry Democrats Study the Tea Party Playbook
BYLINE: By JONATHAN MARTIN
SECTION: Section A; Column 0; National Desk; POLITICAL MEMO; Pg. 16
LENGTH: 1117 words
AVENTURA, Fla. -- Freshly energized protesters are taking to the streets, members of Congress are being confronted in their districts by constituents angry over health care, and wealthy donors are turning fear into action.
Eight years after Republicans united after a stinging electoral defeat to oppose President Barack Obama, Democrats are channeling an even deeper anxiety over President Trump -- and a far shallower defeat -- into a newfound burst of organizing.
Party leaders, eyeing the huge protests last weekend and growing worries over the promised repeal of the Affordable Care Act, are hoping to recreate the mass movement that sprang up in 2009 and swept Republicans to power in the House and in governor's races across the country -- a Tea Party equivalent from the left.
And they are turning to the same playbook that guided their conservative counterparts in the aftermath of Mr. Obama's election: creating or expanding a number of groups outside the formal architecture of the party, focusing on often-overlooked state legislative and redistricting campaigns, and bringing together frightened fund-raisers to underwrite it all.
Recreating the conditions for a second lightning strike will be difficult. The kind of soaring unemployment that followed the worst recession since the Depression is not likely anytime soon, and with many House districts gerrymandered by Republicans and few Republican-held Senate seats open in 2018, the political terrain is more forbidding for Democrats now. Only two Republican Senate seats -- in Nevada and Arizona -- are plausibly available to Democrats at the moment, while Democrats must defend 10 seats in states won by Mr. Trump. The most hard-fought campaigns may be the 38 governor's races that will take place over the next two years.
But in the fury at Mr. Trump and, specifically, the brewing anger over the Republican attempt to repeal the Affordable Care Act, Democrats see passions on their side and the same potential for overreach that animated conservative voters in 2009 and 2010.
''You can see this health care thing just unraveling right in front of them,'' said James Carville, the longtime Democratic strategist, invoking the political maxim that ''the mover on health care loses.''
''To do something is to lose.''
The left begins with a head start: Mr. Trump is already far more unpopular than Mr. Obama was at the outset of his presidency.
The looming question is whether Democrats can sustain the passion of their contributors and activists once the shock of Mr. Trump's inauguration wears off. The success of the post-Obama Democratic Party will be determined by whether the progressives who are roused right now will open their checkbooks and show up at their local Democratic committees in the lead-up to the 2018 midterm elections.
Democrats must ''rebuild from the grass roots up and go back to being competitive in state and local elections,'' said Eric T. Schneiderman, New York's attorney general and a Democrat. ''Even if Hillary Clinton had won, the Republicans still would be controlling 69 of 99 state legislative chambers and 33 governor's mansions.''
The depth of the party's problems was a recurring theme as donors, still in disbelief over Mr. Trump's election, gathered over inauguration weekend at a palm-tree-shaded golf resort here to plot their comeback and tune out the transfer of power 1,000 miles to the north.
David Brock, the combative Democratic organizer, brought together about 150 contributors and operatives for a three-day conference that underscored the opportunity that liberals have and the challenges they face in trying to create their answer to the Tea Party.
That the hard-charging Mr. Brock -- polarizing even among Democrats and identified chiefly with Mrs. Clinton -- could summon a broad array of progressives was an indication of the energy coursing through the left.
Strolling by the pool and talking about how to rebuild, in between presentations with titles like ''What the Hell Just Happened?,'' the donors expressed a determination to fight back.
''There's a real urgent energy,'' said Susie Tompkins Buell, one of Mrs. Clinton's top fund-raisers. ''This is bigger than women's rights, this is bigger than human rights, this is bigger than the environment. This is the future of the entire world.''
Mr. Brock said he would ask for $40 million this year for his constellation of research and advocacy groups, increasing the individual budget of each.
A host of other progressive groups are broadening their ambitions, as well, including the Center for American Progress, a research group, and Priorities USA, which served as the primary ''super PAC'' for Democratic presidential candidates in the last two elections. Some liberals who are part of the Democracy Alliance, a progressive umbrella group, are irritated that Mr. Brock staged the event, fearing that he is creating a competitor to their conferences.
Such jostling for organizational supremacy was also a feature of the conservative landscape when the right formed its resistance to Mr. Obama.
But Democrats are already contending with challenges that Republicans never fully confronted after 2008. There was something close to unanimity on the right in its opposition to Mr. Obama's agenda. The Affordable Care Act did not win one vote from a congressional Republican. But Democrats are at odds over whether they should oppose Mr. Trump across the board or selectively work with him where they have common interests.
Putting his marker down in that debate, Mr. Brock told donors that the ''coming divide'' in the party would be ''between those who resist and oppose and those who accommodate and appease.''
A debate over Mr. Trump's first 100 days broke out at a session here, with Mayor Rahm Emanuel of Chicago pressing for accommodation at times and Ron Klain, a veteran Democratic operative, urging total opposition.
''My attitude is, there will be things that in the interest of the country we're going to work on, and things we're not because it's not in the best interest,'' Mr. Emanuel said.
The debate pointed to a more fundamental difference between the political right and left, which could make Democratic unity more difficult: While conservatives are glad to reap the political benefits from halting or undermining an expansion of government, liberals are invested in a well-functioning state.
''You're going to have a harder time getting Democrats to say, 'We don't want government to work,''' said Mr. Schneiderman, who was a panelist at the event.
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URL: http://www.nytimes.com/2017/01/23/us/politics/justice-democrats-liberal-progressive.html
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A Tea Party protest against the Affordable Care Act at the Capitol in 2009. Democrats hope to stir their own mass movement. (PHOTOGRAPH BY LUKE SHARRETT/THE NEW YORK TIMES)
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March 8, 2017 Wednesday
Late Edition - Final
A Republican Plan to Ration Care
BYLINE: By EZEKIEL J. EMANUEL, AARON GLICKMAN and EMILY GUDBRANSON.
Ezekiel J. Emanuel, an oncologist and a vice provost at the University of Pennsylvania, advised the Obama administration on the Affordable Care Act. Aaron Glickman and Emily Gudbranson are his senior research fellows.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTORS; Pg. 23
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It looks as if Republicans want to bring back health care rationing.
In 2010, Mark Price, a 37-year-old resident of Goodyear, Ariz., was struggling to pay the bills for his leukemia treatment. His house was under foreclosure. He had insurance through Medicaid, and yet he died after the state said it would not pay for a potentially lifesaving bone marrow transplant.
Facing a $2.6 billion budget deficit, Gov. Jan Brewer and Arizona Republicans had opted to ration care, eliminating state payments for bone marrow, liver, heart, lung and other transplants. Simultaneously, the state changed eligibility rules to cut health care for 47,000 low-income children and 310,000 low-income adults.
Arizona was not the only state that cut lifesaving health care benefits during the Great Recession. In 2010, Indiana's Medicaid program denied an infant with a deadly rare disease a tissue transplant, reversing course only after local media coverage led to public outrage.
If the Republicans replace the Affordable Care Act with the plan released on Monday, we should expect more stories like those.
First, the Medicaid rolls will shrink. The Affordable Care Act extended Medicaid to all Americans earning under 138 percent of the federal poverty line -- $16,643 for a single person and $33,948 for a family of four in 2017. Under the Republican plan, enrollment in the Medicaid expansion will freeze starting in 2020. The 11 million Americans who already gained coverage can, in theory, keep it -- but only if they never let their enrollment lapse or their incomes rise.
Then Republicans want to go further, by changing how all of Medicaid is funded: They would replace federal Medicaid payments, which guarantee coverage to anyone who qualifies, with so-called per-person allotments, or per-capita caps. These give states a fixed amount of money for each person on Medicaid, adjusted based on whether the person is blind, disabled, a child, an adult or elderly. The states then decide how to budget the money.
The problem is that the amount given to the states will not keep up with projected health care costs. Changes in the allotment will be tied to changes in the medical part of the Consumer Price Index, which, for various reasons, is unlikely to increase as quickly as the cost of health care. This shortfall in federal funding will force more states to make the kinds of rationing choices Arizona and Indiana made.
A second hidden kicker is that the grants will not increase in response to changing needs. Currently, federal funding is tied to actual Medicaid costs. So if a state has a natural disaster or an epidemic that unexpectedly increases spending, federal funding automatically increases, too. But the Republicans' allotments will not respond to real-world changes. Again, this will force states to make more difficult choices -- cutting lifesaving treatments or nursing home care for the elderly or support for disabled children.
The Republicans say they want to give states more flexibility. But that flexibility most likely means they could use the money for non-health-care programs, or to close state budget gaps. When given budgetary flexibility with large sums of money, this is a common state tactic.
In 1998, as part of a major settlement with tobacco companies, in which the companies agreed to pay Medicaid costs related to lung cancer, emphysema and other smoking-related illnesses, states got a windfall of a minimum of $206 billion over 25 years. What did they do with the money? A 2001 Government Accountability Office report found that 26 percent was being spent on non-health programs, including infrastructure and budget shortfalls. A mere 7 percent was spent on programs related to getting people to stop smoking.
State flexibility has led to other coldhearted decisions. Before the Affordable Care Act, Medicaid was a categorical program, meaning that Americans were eligible only if they were low-income and had another qualifying condition, such as being a child or pregnant or disabled. States could determine those eligibility requirements. And financial pressures made many pretty callous.
In many states, non-disabled working adults were denied any Medicaid benefits. In Wyoming, a working family of three with an income over $9,480 was not eligible for Medicaid. In Alabama, that family had to make just $4,392 -- 24 percent of the poverty line -- to be denied coverage. These people were not lazy or, in Mitt Romney's words, ''takers.'' About 67 percent of uninsured Americans were in families with at least one full-time worker, and more than 10 percent worked two jobs. The uninsured just happened to work for companies that did not or could not provide health insurance.
State flexibility is a ruse. Per-person allotments are an elaborate cost-shifting mechanism -- a fancy way to reduce federal funding and transfer financial responsibility for the health care of low-income Americans to states. A 2014 assessment by the Center on Budget and Policy Priorities of Representative Paul Ryan's plan, which contained elements similar to those in the current proposal, estimated that this accounting trick would increase Medicaid costs for state budgets by $169 billion by 2026. So, under the banner of flexibility, the current Republican plan would force states to make a series of Hobson's choices.
This would be even worse than going back to the days before the Affordable Care Act. It would force states to ration care and deny some Americans lifesaving treatments or nursing home care. Cruel only begins to describe the Republican plan.
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URL: http://www.nytimes.com/2017/03/07/opinion/how-republicans-plan-to-ration-health-care.html
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September 11, 2013 Wednesday
House G.O.P. Delays Vote on Stopgap Budget Measure
BYLINE: JONATHAN WEISMAN
SECTION: US; politics
LENGTH: 304 words
HIGHLIGHT: Republican leaders scrapped a vote this week on legislation that would keep the federal government financed through mid-December while ending financing for President Obama’s health care law.
Facing another revolt by the House's most ardent conservatives, Republican leaders scrapped a vote this week on legislation that would keep the federal government financed through mid-December while ending financing for President Obama's health care law.
The leaders say they will bring the measure up next week, but with just a handful of legislative days left until a government shutdown, Republicans are in a squeeze. Democrats are uniting in opposition to the bill, not only because of the resolution to starve the Affordable Care Act, but also because the level of financing for the government would reflect the across-the-board spending cuts known as sequestration.
For their part, dozens of House conservatives have pledged never to vote for financing legislation that does not kill off the health care law - and they say the structure of the House legislation is a sleight of hand that would not impair the law at all.
In a sense, they are right. Under the complicated structure of the bill, lawmakers would be given a single vote to pass the short-term financing measure, with a separate resolution on the health care law. The health care resolution would then move to the Democrat-controlled Senate, where it would be voted down. After Senate action, the House would send over the financing bill with no attached policy prescriptions.
Some senior Republican aides say that as long as House Republicans remain united in opposition, they don't see how the package can pass. But House leadership aides expressed confidence that the revolt could be cooled down by next week.
10 Questions for Tom Cole
Obama and G.O.P. Spar Over Direction of Cuts
Obama Tells House Democrats He Will Confront Republicans on Taxes
Ryan Expects Debt Deal but Takes Taxes Off the Table
G.O.P. Congressman's Remarks Undermine Party's Immigration Efforts
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March 25, 2017 Saturday
Late Edition - Final
Bracing for Fallout After Bill's Collapse
BYLINE: By MICHAEL D. SHEAR; Alan Rappeport contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 1376 words
WASHINGTON -- Friday's collapse of Republican plans to repeal and replace the Affordable Care Act has broad implications not only for the nation's health care system, but also for the fate of President Trump's ambitious agenda in his young and chaotic presidency.
On Capitol Hill, the failure of newly empowered Republicans to make good on their biggest campaign-year promise exposes the deep divisions that remain in the party. It also, importantly, raises profound dangers ahead of next year's midterm elections.
Taken together, the lessons for the new president and his Republican allies are difficult but necessary if they want to succeed in making progress during the next three and a half years.
House Speaker Paul D. Ryan said on Friday that the lesson from defeat is that ''doing big things is hard.'' Republicans, he said, are eager to ''step up our game, to deliver on our promises.''
Mr. Trump, in remarks from the Oval Office after admitting defeat, said he had ''learned a lot about the vote-getting process'' and called the legislative failure an ''interesting experience.''
For both men, those comments almost certainly understate the impact of Friday's stunning outcome. Here are five takeaways from the day:
The Survival of Obamacare
The most obvious result from the Republican failure on Friday is the immediate survival of the Affordable Care Act. Those who want to buy plans from HealthCare.gov can continue to do so. Families covered by Medicaid will still have insurance. People who saw premiums rise or choices shrink will remain frustrated. And the eight-year political war over the law will continue to be waged.
Democrats crowed when Republicans pulled back their repeal. But the celebrating will be temporary, as Representative Elijah E. Cummings of Maryland noted. ''Americans can breathe a small sigh of relief,'' he said in a statement, ''for now.'' The Republican assault on President Barack Obama's health care law may continue even without a legislative overhaul as administration officials continue to pick away at its regulatory underpinnings.
The Affordable Care Act was always designed to require continuing support to succeed. Each year, the federal government mounts an advertisement campaign to boost enrollment -- something that may no longer happen in a Trump administration. Other regulatory changes could cause problems for the stability of the insurance marketplaces.
The dangers to the law were underscored by Mr. Trump himself, moments after Republicans abandoned their legislative efforts. ''When it explodes, they'll come to me to make a deal,'' Mr. Trump told The New York Times's Maggie Haberman. Any hope that Friday's experience might encourage Mr. Trump to work with Democrats to fix the law's shortcomings died with that statement.
''Today's result is seven years in the making,'' said Dan Pfeiffer, a senior adviser to Mr. Obama. ''The Republicans focused all of their health care energy on the Obama part and none of the care of Obamacare, and therefore were terribly ill-prepared for the moment it came time to actually do something.''
Trump's Personal Capital
Mr. Trump won the White House by selling an image. He told people he was the dealmaker who would get his way -- with foreign leaders, chief executives and with Congress -- through the strength of his personality and his negotiating skills.
That, more than anything, was undercut by Friday's failure. Having fundamentally misread the likelihood of success, Mr. Trump and his advisers fully embraced the health care legislation. While the president never slapped his name on the bill, he happily accepted the personal challenge of getting it passed.
''By our count,'' Sean Spicer, the White House press secretary, bragged just hours before the bill died, ''over 120 members have personally had a visit, call or meeting here at the White House in the past few days, which is an extraordinary feat.''
Having invested his political capital in the outcome of the legislation, Mr. Trump's personal brand has been diminished, according to Republicans who watched the health care debate.
''This is a moment of time, when you're skulking around the family chambers in the White House residence, where you take stock of where you are,'' said Steve Schmidt, a Republican strategist who helped run Senator John McCain's presidential campaign in 2008.
''It's a startling setback,'' Mr. Schmidt added.
The Republican Agenda
Mr. Trump and the Republican Party are moving on. Having spent 64 of his first 100 days pursuing an ultimately futile effort to overhaul health care, the president now must move quickly to try to make good on his other promises -- tax reform, a border wall and investment in infrastructure.
That may all be harder now. Lawmakers who disagree with Mr. Trump have seen him buckle in the face of pressure. And Republican lawmakers may be inspired by the success of the Freedom Caucus -- which wanted to defeat the health care legislation -- to fight for their own interests.
That may be particularly dangerous during an effort to overhaul the nation's tax code. That process is famously difficult, with every change producing winners and losers, all of them ably represented by powerful lobbies.
Mr. Trump seems unfazed -- or unaware -- of that prospect. In comments to reporters, Mr. Trump vowed to ''start going very, very strongly for the big tax cuts and tax reform. That will be next.''
If tax reform becomes defined just as ''big tax cuts,'' the president might find a more unified Republican Party on Capitol Hill. But if he seeks fundamental changes to the kinds of deductions and credits that have been added over decades, he may soon face similar intraparty disagreements.
Steven T. Mnuchin, the Treasury secretary, said at an event sponsored by Axios on Friday that he thought tax reform would be ''simpler'' than passing health reform. But lobbyists from almost every industry have been busily chipping away at parts of the proposal that Mr. Ryan drafted last summer and that powerful groups such as the billionaire Koch brothers, the Club for Growth and the National Retail Federation have come out against.
Representative Kevin Brady, the Republican chairman of the Ways and Means Committee, is hopeful nonetheless.
''This made a big challenge more challenging but it's not insurmountable, so we're going to pivot straight to this and just roll forward,'' Mr. Brady said on Fox News.
The Midterms Are Looming
But even as Mr. Trump and Republicans try to turn to other agenda items, the 2018 midterm elections loom large on the horizon.
Most presidents face losses during their first midterm elections, as voters take their first opportunity to express their opinions of his presidency. And few have had the kind of difficult first year that Mr. Trump has already endured, including approval ratings that are in the 30s -- much lower than most of his predecessors.
Republican lawmakers will head home for spring break next month to explain the health reform failure. Conservatives may brag that they prevented something worse. But many voters will struggle to understand why a repeal didn't happen with Republicans in full control in Washington.
''They are going to blame the feckless, corrupt Republican Congress that they've always hated,'' Mr. Schmidt predicted. ''Dark and ominous clouds are about to blow in over Mount Election 2018.''
The best electoral hope for most Republican lawmakers may be to move away quickly from Friday's loss.
But election season -- a time when legislative success is usually hard to achieve -- will come more rapidly than they like. Lawmakers often say legislating is only really possible in the first 200 days of a president's term.
''The challenge there is that for a lot of big-ticket legislative items, you have a very small window to make big gains on those initiatives,'' said Kevin Madden, a Republican strategist and former top adviser to Mitt Romney, the party's 2012 Republican nominee.
''A good amount of time has already been spent,'' Mr. Madden said. ''You have to quickly move to reorient your agenda so you can maximize your time.''
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
URL: http://www.nytimes.com/2017/03/24/us/politics/trump-agenda-obamacare-midterms.html
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The New York Times Blogs
(You're the Boss)
October 2, 2012 Tuesday
Revisiting President Obama's Small-Business Tax Cut Claims
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 635 words
HIGHLIGHT: A reader asks whether the Obama administration really has cut small-business taxes 18 times.
This summer, the number 18 has crept into President Obama's campaign speeches -- as in, "We've cut taxes for small businesses 18 times." (That's from a speech in Melbourne, Fla., last month.) The first lady, Michelle Obama, mentions it, too. And, of course, it came up frequently at the Democratic National Convention a few weeks ago, where it caught the attention of a regular You're The Boss commenter who calls himself Einstein. (No, not that Einstein.)
"Which small businesses had their taxes cut?" Einsteinrecently asked. "Hate to be skeptical but I know a lot of small-business owners and independent contractors and they never heard of ANY tax cuts. All this talk of helping small business from both political parties sounds like lip service. What are the facts?"
Happy to oblige, Einstein. Back in 2010, when the administration's boast was that it had merely cut taxes 16 times, The Agenda wrote a post about it. Here are the White House's 16 "tax cuts."
From the 2009 stimulus, the Affordable Care Act, and other legislation:
A new small-business health care tax credit.
A tax credit for hiring unemployed workers in 2010.
Temporary extension of bonus depreciation tax incentives to support new investment.
75 percent exclusion of small-business capital gains, for stock acquired in 2009 and 2010.
Temporary expansion of limits on small-business expensing.
Five-year carryback of net operating losses, available through fall 2009.
Reduction of the built-in gains holding period for small businesses to seven years, from 10, in 2009 and 2010.
Temporary small-business estimated tax payment relief. Tax provisions in the 2010 Small Business Jobs Act (both The Agenda and the I.R.S. have published summaries):
100 percent exclusion of small-business capital gains, for stock acquired in late 2010 and 2011.
A further increase to the expensing limit to $500,000 for 2011 (in 2012, the limit falls to $139,000).
A further extension of 50 percent bonus depreciation through 2010.
A new deduction for health care expenses for the self-employed in 2010.
Tax relief and simplification for cellphone deductions.
An increase in the deduction for entrepreneurs' start-up expenses in 2010.
A five-year carry-back of general business credits in 2010.
Lower penalties for failing to report listed (that is, abusive) tax shelters.
Since then, the president has added two more tax cuts to the list, according to a Small Business Administration spokeswoman, who supplied an update:
Increasing bonus depreciation to 100 percent for 2011 (from the Tax Relief, Unemployment Insurance Reauthorization and Job Creation Act of 2010, the compromise law that keeps the Bush income tax cuts in place through this year; for 2012, bonus depreciation falls to 50 percent and then expires).
Tax credits for hiring veterans, ranging from $2,400 to $9,600 (from the Veterans Opportunity to Work to Hire Heroes Act of 2011).
As you can see, some of these aren't tax cuts in the way many people would define them. Rather, they're tax incentives - you've got to spend money (on health insurance, a new employee or new equipment) to save money. Several are improvements or extensions of previous tax incentives. (By that score, some other measures could also be counted as tax cuts, but don't appear on the administration's list - for example, the 2010 Small Business Jobs Act further reduced the built-in gains period to five years for an asset sold in the 2011 tax year.) And, of course, most were temporary, and have already expired.
So has the president really cut taxes 18 (or more) times? We've reported - now you decide.
Why the Health Care Tax Credit Eludes Many Small Businesses
1099 Repeal Passes Senate, Heads to White House
Did Obama Really Cut Small-Business Taxes 16 Times?
1099 Repeal: Now What?
What Obama's Budget Means for the S.B.A.
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The New York Times
January 7, 2013 Monday
Late Edition - Final
Scorecard on Health Insurance Exchanges
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 18
LENGTH: 343 words
Twenty-three states, most led by Republican officials, have declared that they will not set up their own health insurance exchanges to help individuals and small businesses find affordable coverage. Instead, they want to offload that task to the federal government.
In the short run it will not matter much who runs the exchanges. Consumers will be able to buy essentially the same policies and receive the same consumer protections either way. But in the long run, it would be best if states took on the job because they have the knowledge needed to mesh state and federal programs and encourage participation by local insurers and health care providers.
Under the Affordable Care Act, health insurance exchanges will serve as online marketplaces that will allow people to choose among insurance plans whose costs and benefits are easy to compare. The federal government will provide tax-credit subsidies to help pay premiums for people with incomes just above the levels allowed by Medicaid programs. The exchanges are supposed to be ready to enroll people by Oct. 1 for coverage that will start on Jan. 1, 2014.
Federal health officials announced last Thursday that 17 states and the District of Columbia are moving to set up their own exchanges. Seven other states have said they want to collaborate with the federal government to set up exchanges (states have until Feb. 15 to sign up for such partnership arrangements). A federal exchange will be available for all states that refuse to take any action.
The Affordable Care Act gives the Department of Health and Human Services responsibility for determining what ''essential health benefits'' must be provided by insurers and for designing Web sites for comparing plans, among other duties. The act also provides basic consumer protections, like the right to buy insurance without regard to health status, that apply both on and off the exchanges. Residents of states where political leaders seem bent on frustrating or sabotaging the health care reforms might well be better off with a federally run exchange.
URL: http://www.nytimes.com/2013/01/07/opinion/scorecard-on-health-insurance-exchanges.html
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The New York Times
December 11, 2014 Thursday
Late Edition - Final
Many States Unprepared to Set Up Health Exchanges
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; Pg. 3
LENGTH: 978 words
A Supreme Court ruling next spring could upend health insurance markets in at least 34 states, eliminating the federal subsidies that make coverage affordable for millions of Americans.
State governments, theoretically, have ways to forestall this outcome. But few have taken action. If they wait until the court rules, it may already be too late for a state to get started on an exchange so that it is ready for 2016.
The case, called King v. Burwell, concerns whether subsidies can be given to consumers in every state in the country or only in those that have established their own state marketplaces as part of the Affordable Care Act. So far, more than a dozen states and the District of Columbia have such marketplaces. Should the court rule that subsidies can be distributed only in states running their own exchanges, markets in the remaining states would be substantially disrupted. Prices for insurance plans would sharply rise. Millions of people would drop their coverage.
A decision in the court case is expected in June; a new marketplace would need to be ready for shoppers in October in order to sell health plans for 2016. If those states want to make sure that subsidies keep flowing to their residents, they can build their own marketplaces. But it won't be easy.
''Anyone who thinks you can just snap your fingers and you've got a state exchange is just wrong,'' said Timothy Jost, a law professor at Washington and Lee University, who supports the Affordable Care Act.
Congress could prevent or eliminate a disruptive outcome by changing some language in the Affordable Care Act. That change may be more politically fraught than state-level actions in some parts of the country.
The new health care law lays out a series of clear requirements for state exchanges -- some political, some operational. None of them are trivial.
The political challenges, for one, are substantial. States would need to endorse an exchange through legislation or executive action, as they have declined to do previously. The Affordable Care Act is so unpopular in some of these states that they have passed legislation explicitly barring the governor from establishing an exchange. And only eight states' legislatures will even be in session in June when the court is expected to rule, according to David K. Jones, an assistant professor at the Boston University School of Public Health, who has studied the state exchange decision-making process and is a co-author of a recent essay in The New England Journal of Medicine detailing the difficulties states will face.
Then there are the operational challenges. Every state marketplace needs a staff and the ability to carry out a series of core functions, including regulating insurance plans, running a call center and managing a website that can enroll people in insurance coverage. Some of the states relying on the federal government are doing one or two of these functions, in an arrangement known as a partnership exchange, but most are not.
Most states will rely on contractors for major tasks, and state laws tend to require a lengthy process for contract procurement that can run six months or longer. Once contracts are signed, the states still need to hire call center employees, devise policies and build the website and its infrastructure.
Many of the 15 state marketplaces that started up last fall struggled to accomplish all of those things. Several states experienced website crashes and failures. And those early states had had more than three years to approve and design their exchanges.
Daniel Schuyler, a director at Leavitt Partners, a consulting firm that helped several states establish exchanges, estimates that building an exchange today would cost a typical state from $40 million to $60 million and take between a year (if a state expedited its contracting schedule) and 18 months.
That would be faster than most states with their own exchanges managed in recent years, as well as less expensive. Late adopters would have the advantage of accumulated wisdom that the early states didn't have. They also would benefit from software and computer network contractors with more experience building the necessary computer systems. This year, Massachusetts replaced its failed software with an off-the-shelf product from another contractor. But it still needed to be retrofitted to work with the state's system.
''You can buy an engine off-the-shelf, and an engine is the most important thing to make a car run,'' said Nicholas Bagley, an assistant professor at the University of Michigan Law School, and the other author of The New England Journal article. ''But you can't drive something off the lot with just an engine.''
States waiting until now to act won't have access to a substantial pot of federal money to help them get off the ground. States that have established exchanges so far sought substantial establishment grants from the federal government. By law, that funding stream expires at the end of the year, and the deadline for the last round of grant applications has already passed. (A few states that have been considering creating an exchange put in for the money.)
By law, all state exchanges must be financially self-supporting next year, which means that any states that start a new one will have to make a substantial initial investment.
''States don't have any appetite to dip into their own coffers,'' said Mr. Schuyler, who said his firm had talked with a few states about the possibility of starting a state exchange.
All of which means that the effect of a court ruling dismantling federal subsidies could be both substantial and lasting in large parts of the country. States will have the power to get subsidies to their residents. But not easily, and not right away.
''This is really going to be much more difficult for states to do quickly than a lot of people think,'' Mr. Jones said.
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(In Practice)
October 1, 2013 Tuesday
Health Care Coverage Business Is Bustling at New York City Hospital
BYLINE: Katie Thomas
SECTION: US
LENGTH: 487 words
HIGHLIGHT: New York’s Montefiore Medical Center has extensive outreach program to help consumers choose healthcare coverage.
Miosotis Munoz stood outside the main entrance to Montefiore Medical Center in New York on Tuesday, calling out to the throng of patients, hospital workers and other passers-by with all the enthusiasm of a carnival barker. But on this day, Ms. Munoz was selling health care, not hotcakes.
"Do you want to learn more about affordable health care?" she asked, in English and Spanish, near a promotional sign for New York's health insurance marketplace that read "Today's the Day."
Ms. Munoz, a community relations manager, was helping to staff an informational booth outside the hospital on Tuesday as part of Montefiore's extensive efforts at helping patients and other community members enroll in insurance under the new health care law.
Hospital administrators had initially wondered how many people would show up, but by noon on Tuesday, they had their answer: the booth was bustling. The questions were as diverse as the crowd that approached the tables - some were nurses and other hospital workers, asking for information for friends and neighbors. Others were regulars at Montefiore's health clinics who were hoping to get more comprehensive coverage. Still others had been researching their options online and wanted to put their questions to a real person.
Beatriz Nunez was bringing her mother, who receives Medicaid and Medicare, to the hospital for X-rays but stopped at the booth to pick up information for herself. Ms. Nunez, who is 25, works as a secretary but said her boss did not pay for health insurance. She said she had applied for Medicaid in the past but was told she made too much. Buying private insurance was too expensive, she said.
"I spoke with my doctor a while back and he said, 'wait for Obamacare to kick in,'" she said. "The sooner I can apply, the better."
Michael Echevarria, 33, works in the hospital gift shop - which is run by an outside entity - and said he could not afford the health insurance that his employer offered. He was curious about his options and confused by the onslaught of news coverage in recent days. "I've heard a lot of different things - we have to have it, we don't have to have it, the government is shutting down," he said.
Like Ms. Nunez, Mr. Echevarria said he was interested in buying health insurance and had been told previously he did not qualify for Medicaid. He said doctors had warned him he was prone to diabetes and had kidney troubles, but those conditions have largely gone untreated. He sometimes visits a free health clinic intended for homeless people to get care, he said. Having health coverage would be a relief, he said, but he's still not sure he can afford it. "I've got to do the math," he said.
Health Insurers Report High Volume of Queries on Health Care Coverage
At a Miami Health Center, Told to Come Back Another Day
For Many, Personal Service Is More Helpful Than Web Site
Polls in Overtime on Affordable Care Act
A Scramble as Day 1 Approaches
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The New York Times
September 25, 2013 Wednesday
The New York Times on the Web
Obama and Clintons Share Stage for Health Care Talk
BYLINE: By MICHAEL D. SHEAR
SECTION: Section ; Column 0; Washington; Pg.
LENGTH: 618 words
After delivering a much-anticipated speech to the United Nations General Assembly in the morning and meeting with world leaders in the afternoon, President Obama turned to health care on Tuesday evening, sharing center stage with the Clinton family at an event to highlight the rollout of the Affordable Care Act.
Mr. Obama joined former President Bill Clinton; his wife, Hillary Rodham Clinton, the former secretary of state; and their daughter, Chelsea Clinton, at the Clinton family foundation's annual convention just blocks away from United Nations Plaza. White House officials said the rare, hourlong appearance by the two presidents was an attempt to bring attention to next week's opening of enrollment in health insurance exchanges that are at the center of the Affordable Care Act.
The conversation turned out to be a policy-heavy discussion about the financial reality of America's health care system and what Mr. Obama's health care law would attempt to do about it. Mr. Clinton -- famous for being long winded -- as technically the interviewer and Mr. Obama the subject. But both men took long turns with the microphone.
''In the last three years, just since we started doing this, inflation in health care costs has dropped to 4 percent for three years in a row for the first time in 50 years -- 50 years,'' Mr. Clinton said. ''So before that, the costs were going up at three times the rate of inflation, for a decade.''
He later noted that before the health care law went into effect, ''80 percent of the American states had only one or two companies providing health insurance who had more than 80 percent of the market.''
''So there was, in effect, no price competition,'' he said.
The new law, Mr. Clinton added, has ''actually led to the establishment of more companies doing more bidding.''
Mr. Obama spent much of his time responding to critics by methodically laying out the benefits that people will receive once the health law is in place. And he urged young and uninsured Americans to sign up for coverage, saying it would not cost them much to do so.
''Just go to the Web site yourself, go to, you know, healthcare.gov, take a look at whether this is a good deal or not,'' he said. ''When people look and see that they can get high-quality, affordable health care for less than their cellphone bill, they're going to sign up. They are going to sign up.''
Earlier, Mrs. Clinton introduced her husband and Mr. Obama, noting their many similarities.
''They're both left-handed. They both love golf -- a game that does not often reciprocate the love they put into it,'' she said. ''They both are fanatic sports fans and go to great lengths to be in front of the TV or on the side of the court or the field. They both are master politicians. Each of them has only lost one election. They are both Democrats. They have fabulous daughters.''
And finally, she said with a broad smile: ''They each married far above themselves.''
In recent months, Mr. Obama has reached out to Mr. Clinton to help with the health care rollout, which faces an aggressive Republican campaign to derail it. Mr. Clinton, who failed to secure a health care overhaul while he was in office, has accepted the challenge.
The spotlight on the Clintons has grown larger this year as speculation has mounted about Mrs. Clinton's presidential ambitions in 2016.
In an interview in New York magazine this week, she conceded that she is thinking about running.
''I will just continue to weigh what the factors are that would influence me making a decision one way or the other,'' she said in the interview ''I'm not in any hurry. I think it's a serious decision, not to be made lightly, but it's also not one that has to be made soon.''
URL: http://www.nytimes.com/2013/09/25/us/politics/obama-and-clintons-to-share-stage-to-talk-health-care.html
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The New York Times Blogs
(You're the Boss)
October 18, 2012 Thursday
Jon Stewart Proposes an Entrepreneurial Policy. Don't Laugh.
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 710 words
HIGHLIGHT: The Comedy Central host is proposing that rather than cut taxes to amplify the rewards of success, we should find ways to ease the damage done by failure.
The Daily Show
Jon Stewart said something provocative about entrepreneurship on The Daily Show a few weeks back - and it involved only a little cursing. The occasion was the Democratic National Convention, and while interviewing the former Obama economic adviser Austan Goolsbee, the host had this to say about the conservative talking point that taxes discourage "job creators" from taking big risks by pinching the rewards:
What we need to do in this country is make it a softer cushion for failure. Because what they say is the job creators need more tax cuts and they need a bigger payoff on the risk that they take. But what about the risk of, you're afraid to leave your job and be an entrepreneur because that's where your health insurance is? Why aren't we able to sell this idea that you don't have to amplify the payoff of risk to gain success in this country, you need to soften the damage of risk?
Mr. Stewart says this at the beginning of the third part of the interview, which is only available online. (Warning: some profanity.)
The Agenda has often wondered if decoupling health insurance from employment might encourage entrepreneurship. But Mr. Stewart is pushing a bigger idea here of a wide safety net for failure, and an associated trade-off between diminished risks and a diminished reward (presumably reduced by the higher taxes necessary to subsidize those risks). And perhaps one reason nobody has been able to sell that idea is because we've never heard anyone advance it in the public square before.
Mr. Goolsbee, for his part, agreed on the narrower point about insurance. "The data do not support the view that cutting taxes a ton for high-income people leads to lots of jobs for everybody else," he said. "The data back up your idea that not being able to have health insurance, not being able to have social insurance in general - that Social Security's going to be there to support your retirement; that when you retire, there's Medicare that's going to cover your medical expenses - lead people to say, 'I don't want to take a risk, I don't want to go start my own company, because I've got to lock away some money [for] when I retire.'" But he shied away from Mr. Stewart's broader point. "That is a deep question," he told Mr. Stewart, "and I don't totally know."
As Mr. Stewart might say, the guy with the goofy name is right! It is a deep question. And for a country where civic leaders speak so enthusiastically and incessantly about nurturing entrepreneurship and innovation, it raises practical and philosophical issues about just how far we ought to go to do so, and at what cost. We'd like to know what you think.
First of all, what kind of risks could be mitigated or socialized with a failure cushion (I picture it brightly colored, and embroidered with comforting thoughts like, "Well, at least you tried" or "Better luck next time!")? Mr. Stewart mentioned the risk of losing one's health insurance, which could be ameliorated by the new health care law, should it succeed in making affordable health insurance broadly available to people who cannot get insurance at work. It's possible, too, that crowdfunding may allow entrepreneurs to start businesses without putting their life's savings - or their homes - in jeopardy. What else do job creators put on the line when they open up shop, and how might the danger be lessened?
But even if we could socialize the risks of innovation and entrepreneurship, as a practical matter, should we? Most businesses fail now, and that is with barriers in place that discourage starting new businesses. If those barriers were lowered, would the rate of failure grow higher, making the cost of success more expensive? Would the social benefits of success - jobs and spending in the economy - offset those higher costs?
Finally, suppose we do socialize these risks, in exchange for a somewhat smaller payoff: Would entrepreneurs still be interested in pursuing their ventures?
Why the Health Care Tax Credit Eludes Many Small Businesses
A Business Owner Expects the Worst From Health Insurance Overhaul
Small Business Health Insurance: Costs Still Going Up
The Affordable Care Act Rebate Checks Are in the Mail: Now What?
Having Lost the Health Care Battle, the N.F.I.B. Readies for a Long War
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The New York Times
April 4, 2017 Tuesday
Late Edition - Final
Kansas House Upholds Veto of Medicaid Expansion
BYLINE: By ABBY GOODNOUGH and MITCH SMITH; Abby Goodnough reported from Topeka, and Mitch Smith from Lincoln, Neb.
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 757 words
TOPEKA, Kan. -- The Republican-controlled Kansas House of Representatives voted narrowly on Monday to uphold Gov. Sam Brownback's veto of a bill to expand Medicaid, ending a quest that came improbably close to succeeding in this deep red state despite Mr. Brownback's unyielding opposition.
In spite of a torrent of phone calls and in-person pleas from constituents over the weekend, and last-minute lobbying by hospital leaders who said that expanding Medicaid would help save a number of rural hospitals from closing, the vote was 81 to 44, three short of the two-thirds majority needed for an override.
The effort to expand Medicaid to cover 150,000 additional low-income people in Kansas had been closely watched nationally, in part because it came just after President Trump and Republicans in Congress tried and failed to repeal the Affordable Care Act. Success might have provided momentum in some of the other 18 states that have not yet expanded Medicaid under the health law to cover far more low-income adults.
While two Republican lawmakers who had originally voted against expanding Medicaid switched sides and voted to override, two others who had supported the expansion bill when it passed the House in February voted to sustain the veto.
One of them, Representative Clay Aurand, a Republican from Belleville, said he hoped Kansas could find a way to expand Medicaid in ''a more fiscal-neutral way.''
Supporters of the expansion had argued that it could save lives and jobs.
''We have the ability to help people who truly need it the most,'' Representative Cindy Holscher, a Democrat from Olathe, told her colleagues. ''We have the ability to make a decision today that will save lives -- not just one, but potentially thousands.''
Representative Susan Concannon, a Republican from Beloit and a leading proponent of the expansion bill, said, ''What we know most of all is that if we do this, it will prevent closures of hospitals.''
Opponents of expansion questioned whether Kansas could afford it, expressed doubts about whether the federal government would continue to pay for most of it if the health care law eventually is repealed, and suggested the promised benefits to rural hospitals were overstated.
Mr. Brownback vetoed the measure almost as soon as it reached his desk on Thursday, saying that the cost to the state would be ''irresponsible and unsustainable,'' and that it would be ''unwise'' to expand Medicaid while President Trump and Congress were still vowing to repeal the Affordable Care Act.
He also said the bill was unacceptable because it did not include a work requirement for beneficiaries of the Medicaid expansion. While the federal government has never allowed states to require that people have jobs in order to receive Medicaid, the Trump administration has hinted that it may. Some Republican-led states are considering asking for changes to their Medicaid programs that could reduce recipients, including work requirements, premiums and even lifetime limits on Medicaid coverage.
The vote in Kansas came five months after an election in which moderate Republicans and Democrats replaced a number of conservatives in the Legislature, breathing new life into an effort that had stalled for years. The House of Representatives voted 81 to 44 in February to expand Medicaid. The Senate followed last week with a 25-to-14 vote; health committees in both chambers heard often emotional testimony from uninsured Kansans and from medical providers.
The Affordable Care Act originally required all states to expand Medicaid to all adults earning up to 138 percent of the federal poverty level, but the Supreme Court ruled that states could opt out if they wished. Still, the law has played a major role in reducing the number of Americans without health insurance, with about 11 million low-income adults gaining coverage in the 31 states that have chosen to expand the program.
In the 19 states that have not expanded Medicaid -- including some of the biggest, such as Florida and Texas -- millions of low-income people are stuck in a ''coverage gap,'' earning too much for Medicaid under their states' stringent guidelines but too little to qualify for subsidized coverage through the Affordable Care Act marketplaces.
David Jordan, executive director of Alliance for a Healthy Kansas, an advocacy group that formed last year to push for expanding Medicaid, said supporters were not giving up.
''The problem of 150,000 Kansans not having access to health care doesn't go away,'' he said.
URL: http://www.nytimes.com/2017/04/03/health/kansas-brownback-veto-expand-medicaid.html
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GRAPHIC: PHOTO: State Representative Jan Kessinger watching the vote board on Monday as his colleagues in the Kansas House cast their ballots. (PHOTOGRAPH BY NICK KRUG/THE LAWRENCE JOURNAL-WORLD, VIA ASSOCIATED PRESS)
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The New York Times Blogs
(Economix)
November 23, 2012 Friday
Health Insurance Exchanges May Be Too Small to Succeed
BYLINE: DANA P. GOLDMAN, MICHAEL CHERNEW and ANUPAM JENA
SECTION: BUSINESS; economy
LENGTH: 922 words
HIGHLIGHT: Paradoxically, an increase in competition among insurers may lead to higher reimbursements and health care spending, and thus higher premiums, particularly when the medical provider market is not very competitive, three economists write.
Dana P. Goldman is the director of the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California. Michael Chernew and Anupam Jena are professors of health care policy at Harvard University.
With the re-election of President Obama, the Affordable Care Act is back on track for being carried out in 2014. Central to its success will be the creation of health-insurance exchanges in each state. Beneficiaries will be able to go a Web site and shop for health insurance, with the government subsidizing the premiums of those whose qualify. By encouraging competition among insurers in an open marketplace, the health care law aims to wring some savings out of the insurance industry to keep premiums affordable.
Certainly, it is hard to be against competition. Economic theory is clear about its indispensable benefits. But not all health care markets are composed of rational, well-informed buyers and sellers engaged in commerce. Some have a limited number of service providers; in others, patients are not well informed about the services they are buying; and in still others, the quality of the service offerings vary from provider to provider. So the question is: What effect does insurer competition have in a marketplace with so many imperfections?
The evidence is mixed, but some of it points to a counterintuitive result: more competition among insurers may lead to higher reimbursements and health care spending, particularly when the provider market - physicians, hospitals, pharmaceuticals and medical device suppliers - is not very competitive.
In imperfect health care markets, competition can be counterproductive. The larger an insurer's share of the market, the more aggressively it can negotiate prices with providers, hospitals and drug manufacturers. Smaller hospitals and provider groups, known as "price takers" by economists, either accept the big insurer's reimbursement rates or forgo the opportunity to offer competing services. The monopsony power of a single or a few large insurers can thus lead to lower prices. For example, Glenn Melnick and Vivian Wu have shown that hospital prices in markets with the most powerful insurers are 12 percent lower than in more competitive insurance markets.
So health insurance exchanges are probably welcome news for hospitals, physicians, and pharmaceutical and medical device companies throughout the United States. If health insurance exchanges divide up the market among many insurers, thereby diluting their power, reimbursement rates may actually increase, which could lead to higher premiums for consumers.
Ultimately, economic theory predicts that the effect of insurance exchanges on insurance premiums will depend on two offsetting factors. On one hand, smaller, less-consolidated insurance companies may have less bargaining power with large hospitals, physician groups and pharmaceutical companies, which traditionally command substantial market power. Reimbursements to these parties, as well as costs to insurers, may rise in a fractionated market, and if so, these costs would be passed on to consumers as higher premiums. On the other hand, exchanges may inject competition into the marketplace, reducing premiums as even the smallest insurer can market its plans, forcing larger insurers to lower their premiums to remain competitive. Which theoretical effect will dominate in reality is an open empirical question with important policy implications.
There is some evidence on how insurer market power affects premiums. Leemore Dafny, Mark Duggan, and Subramaniam Ramanarayanan have found that greater concentration resulting from an insurance merger is associated with a modest increase in premiums - suggesting that concentration may not help consumers so much - although they did report a reduction in physician earnings on average. Over all, however, the evidence is limited and mixed.
A simple analysis of the nationwide growth in premiums over the last decade is illustrative. Using 2001-10 data from the National Association of Insurance Commissioners, we examined the relationship between insurer market power (defined as the market share of the two largest companies) and changes in premiums. We found that concentration of insurer power -- hence less competition - was not significantly associated with higher premiums, as can be seen in the chart below.
Hawaii is a good example. Kaiser Permanente and Blue Cross Blue Shield together controlled more than 90 percent of the insurance market in 2001. In this highly concentrated market, the average premium rose only 72 percent over the decade, compared to an overall increase of 135 percent nationwide. By contrast, Virginia had one of the most competitive markets in 2001, with its two largest insurers controlling only 25 percent of the market, yet premiums in the state increased nearly 140 percent over the period.
Greater competition in the insurance industry -- either through health insurance exchanges or other measures -- may not lower insurance premiums. Weakening insurers' bargaining power could instead translate into higher costs for all of us in the form of higher premiums.
In financial markets, we ask if banks are too big to fail. When it comes to health care, perhaps we should ask if insurers are too small to succeed.
Employer-Provided Health Insurance and the Market
From Physician Glut to Physician Shortage
Awaiting the Supreme Court's Health Care Ruling
Health Care: Solidarity vs. Rugged Individualism
The Fork in the Road for Health Care
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March 9, 2015 Monday
Late Edition - Final
Some Justices Cite 2012 Argument Against Health Care Law as Defense for It Now
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 9
LENGTH: 1042 words
WASHINGTON -- In 2012, the Supreme Court declared that Congress had put ''a gun to the head'' of states by pressuring them to expand Medicaid, and it said that such ''economic dragooning'' of the states violated federalism principles embedded in the Constitution.
Now, in a separate case, comments by several justices indicate that they could uphold a pillar of the Affordable Care Act -- insurance subsidies for millions of lower-income people -- by invoking those same principles.
In 2012, the court said it would be unconstitutional for Congress to cut off all Medicaid payments to states that refused to expand eligibility, and this ruling instantly transformed the expansion of Medicaid into a state option.
That precedent echoed through oral arguments last week before the court; justices again expressed respect for federalism and state sovereignty.
Under the health care law, Congress gave states a choice: They could establish and operate their own competitive insurance marketplaces, or they could rely on one established by the federal government. It was, several justices said, inconceivable that Congress would then punish states that used the federal exchange by denying insurance subsidies to their residents.
Justice Anthony M. Kennedy suggested that such a choice could coerce states in a potentially unconstitutional way. Under the theory favored by critics of the health care law, Justice Kennedy said last week, ''the states are being told either create your own exchange, or we'll send your insurance market into a death spiral,'' and ''the cost of insurance will be sky high.''
Mark H. Gallant, a health lawyer at Cozen O'Connor in Philadelphia, said: ''Justice Kennedy's take on this case was a brilliant touch. He used the plaintiffs' own argument against them to suggest that it would be unconstitutionally coercive if Congress made the subsidies depend on a state's decision to establish an exchange.''
Plaintiffs in the case, King v. Burwell, say the Affordable Care Act authorizes subsidies only in states that created their own insurance exchanges.
Justice Antonin Scalia said it was ''gobbledygook'' for the Obama administration to suggest that an exchange set up by the federal government ''qualifies as an exchange established by the state.'' When the language of the law is clear and unambiguous, he said, the court cannot twist the words to avoid ''untoward consequences.''
And Justice Samuel A. Alito Jr. said the court could delay the impact of its ruling if the consequences were as disruptive as the administration said.
But the Obama administration argues that the subsidies are available in all states, including more than 30 that refused to establish exchanges and rely on the federal marketplace. Without the subsidies, it says, many people would be unable to afford insurance, and healthier consumers would go without coverage, leaving insurers with a sicker, more expensive pool of customers.
The Affordable Care Act has begun reducing the number of uninsured in two main ways: by expanding Medicaid and by providing tax credits to subsidize private insurance purchased through the public exchanges. The court, which focused on Medicaid three years ago, is now examining the subsidies.
Justice Sonia Sotomayor told the plaintiffs' lawyer, Michael A. Carvin, that if the court accepted his argument, it would be ''intruding on the federal-state relationship, because then the states are going to be coerced into establishing their own exchanges.''
And Justice Elena Kagan said Congress had not warned states of the consequences if they chose to use the federal exchange. In interpreting statutes, Justice Kagan said, the court presumes that ''Congress does not mean to impose heavy burdens and draconian choices on states unless it says so awfully clearly.''
For decades, more conservative justices have emphasized respect for state sovereignty. The court often uses ''basic principles of federalism embodied in the Constitution to resolve ambiguity in a federal statute,'' Chief Justice John G. Roberts Jr. said in his opinion for the court in an unrelated case nine months ago.
The oral arguments also showed how the court, in the digital age, could be influenced by a flood of research, analysis and commentary from bloggers, scholars and advocates forecasting dire consequences if insurance subsidies end. More than 20 legal briefs have conveyed those concerns to the court, citing studies by groups like the Commonwealth Fund, the Urban Institute, the Kaiser Family Foundation, the RAND Corporation and Families USA.
''In the last six weeks,'' said Abbe R. Gluck, a law professor at Yale, ''people finally woke up and became aware of the drastic real-world consequences.''
A typical study, from the Urban Institute, based on a computer model of the health care system, was titled: ''Implications of a Supreme Court Finding for the Plaintiff in King v. Burwell: 8.2 Million More Uninsured and 35 Percent Higher Premiums.''
When ruling on appeals, judges typically make decisions by closely reading the law and applying it to the facts of a case, as revealed in a trial court. But in the subsidies case, supporters of the health care law found a way to bring their predictions to the Supreme Court justices' attention.
The government argued that Congress could not have imposed such drastic consequences on states without discussing the impact and without giving clear, explicit notice to the states.
''If that was really the plan, then the consequence for the states would be in neon lights in this statute,'' said Solicitor General Donald B. Verrilli Jr.
Justice Kennedy has long been a protector of the states. They need clear notice of the conditions attached to federal funds so they can ''guard against excessive federal intrusion into state affairs and be vigilant in policing the boundaries of federal power,'' he wrote in 1999.
The Affordable Care Act expanded federal power, but preserved a large role for states.
Mr. Carvin, the plaintiffs' lawyer, said the law had offered an irresistible incentive -- ''billions of free federal dollars'' in subsidies -- as an inducement for states to set up exchanges.
''That's hardly invading state sovereignty,'' Mr. Carvin said.
URL: http://www.nytimes.com/2015/03/09/us/politics/some-supreme-court-justices-cite-2012-argument-against-health-care-law-as-defense-for-it-now.html
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February 2, 2013 Saturday
We Can Be Healthy and Rich
BYLINE: EZEKIEL J. EMANUEL
SECTION: OPINION
LENGTH: 839 words
HIGHLIGHT: Controlling health care costs will help, not hurt, the economy.
Just about everyone agrees that health care in America is too expensive, and that something must be done to control the rising costs. Except for one group: hospitals and the unions representing hospital workers.
They believe that controlling health care costs will hurt the economy and increase unemployment. They point out that hospitals are among the largest employers in many communities and that, unlike other employers, they are adding jobs at a good clip.
But the truth is that bending the health care cost curve will actually spur the economy forward. According to the Council of Economic Advisers, reducing health care cost increases by just 1 percentage point every year would lead to a 4 percent increase in G.D.P. by 2030. In today's dollars, that would mean an extra $600 billion for our economy and an extra $7,000 for the average family.
In some ways, it's easy to sympathize with the hospitals' worries: their concern is that competition in the new insurance exchanges and other changes catalyzed by the Affordable Care Act will result in lower premiums. To stay profitable, insurance companies will have to pressure hospitals to reduce their rates. And since 60 percent of an average hospital's costs are labor, employees will be laid off and wages cut. At a time when hospital support jobs pay about 10 percent more and typically come with more generous benefits than comparable jobs in other industries, it's understandable that health care employees are resistant.
But this line of reasoning is misguided. First, cost control is not the same thing as cost reduction. The financial goal of reforms like reducing hospital readmissions and hospital-acquired infections and encouraging competition among insurance companies is to stem the rate of growth in health care spending. We spent about $2.8 trillion on health care last year, and the system wastes approximately $700 billion annually, but no one is proposing that these expenditures decline to even $2.6 trillion. Cost control is simply about staving off the date when health care spending exceeds $4 trillion.
In addition, even if hospitals had to restructure their operations to deliver care more efficiently, it wouldn't necessarily mean fewer health care workers over all - any decline in hospital jobs would probably mean an increase in other health-related jobs like home health aides.
Where the opponents of cost control really go wrong is on the macroeconomics. Layoffs in the health care industry would increase unemployment and lower wages, they argue, thereby reducing consumer spending and hurting the economy. But both liberal and conservative economists agree that ever rising health care spending is a huge drag on the economy. As one of the Heritage Foundation's fellows wrote: "If Americans could attain the current level of health for a lower total cost, the resources saved could be used for some other beneficial purpose, and U.S. economic well-being would undoubtedly improve."
There is a good parallel in the agriculture industry. The introduction of tractors with internal combustion engines in the early 20th century caused unemployment among farmworkers, but it also increased productivity and made food cheaper. In 1920, about 40 percent of an American family's income went to purchasing food. Today the average family spends approximately 10 percent of its income on food, which means more disposable income to spend on other rewarding items - education, appliances, smartphones, computers - and more jobs in these industries.
Health care will follow a related path. Savings won't just disappear. They'll go into other purchases, often ones that are more valuable, like higher education or rapid transit, creating construction jobs while making our commutes easier. Small businesses, if they don't have to cover ever increasing insurance costs, could instead pay higher wages and hire more workers. The estimated reduction in health care premiums because of the Affordable Care Act will mean that in 2019 average families will pay about $2,000 less than they would have without cost control, freeing up money for purchases or retirement.
Some people may argue that they would take a lower G.D.P. and slower growth if it meant that we were healthier. But this, too, is wrong. There is no link between how much we spend and how healthy we are. Many other countries, including Australia, France and Germany, spend less but perform better on many health care measures. It's true even for different regions in the United States: there is no link between higher spending and better health.
It's clear that, far from creating unemployment and hurting the economy, the more we can control health care costs, the more Americans will prosper. Ultimately, however, this debate should be irrelevant. Health care is about keeping people healthy or fixing them up when they get sick. It is not a jobs program.
What We Give Up for Health Care
Philosopher Kings and Fiscal Cliffs
The Hidden Prosperity of the Poor
Spring Sequester
When Paying It Forward Pays Us Back
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January 15, 2017 Sunday 00:00 EST
'Repeal and Replace': Words Still Hanging Over G.O.P.'s Health Care Strategy;
On Washington
BYLINE: CARL HULSE
SECTION: US; politics
LENGTH: 1077 words
HIGHLIGHT: Producing the slogan turned out to be far easier for Republicans than producing an actual replacement for President Obama's Affordable Care Act.
WASHINGTON
In March 2010, on the day before President Obama was to sign the Affordable Care Act into law, a group of senior Republican aides huddled in Senator Mitch McConnell's Capitol suite to try to come up with a catchy slogan to use against it.
Many conservatives were simply advocating a vow to repeal the new law, but Republican strategists worried that pressing for repeal without an alternative could backfire. So they batted around a few ideas before Josh Holmes, then a top communications adviser to Mr. McConnell, tossed out the nicely alliterative phrase "repeal and replace." That seemed to do the job, with its promise to get rid of the new law detested by Republicans while suggesting that something better would follow.
The phrase has shown real staying power: President-elect Donald J. Trump proudly invoked "repeal and replace" twice during his news conference on Wednesday.
"The goal was to come up with something that had durability and could be a rallying cry for Republicans basically to campaign against Obamacare," said Mr. Holmes, now the president of Cavalry, a consulting and media firm. "This obviously had sort of a catchy ring to it. And it was consistent with what we were trying to accomplish."
As it turns out, producing the slogan turned out to be far easier than producing an actual replacement. Almost seven years later, congressional Republicans are still struggling to settle on a consensus alternative to the health care law, endangering their push to quickly undo and then redo the signature Obama administration achievement, which turned out to be a springboard to a Republican political resurgence.
The uncertainty has reignited the fight to define the health insurance program in the public mind, with Republicans and Mr. Trump painting it as a disaster, and Democrats portraying it as a success that provides security to millions of Americans, many of them Trump voters. Democrats have latched on to their own catchphrase, warning that repealing the law will "Make America Sick Again" - a twist on the Trump campaign's "Make America Great Again" theme.
Republicans have derided the Democratic message - personally developed by Senator Chuck Schumer of New York, the new Democratic leader - as trite and ineffective. But Democrats like it and believe that it goaded Mr. Trump into a more direct and complicating role in the Republican deliberations over how quickly to propose a replacement for the health care program.
They say Republicans are still relying on Mr. Holmes's years-old brainchild because they are groping for a replacement with their new unified government days away. Democrats see the confusion as a victory in their push to thwart repeal or slow it down while wringing all the political advantage they can from the attempt.
After a series of late-night Senate budget votes that laid the procedural groundwork for repeal with no certainty on what was to follow, one Democrat delivered a new punch line.
"This is called repeal and run," Senator Claire McCaskill, Democrat of Missouri, said on Twitter as the Senate was voting. "Chaos is coming."
Mr. Trump's involvement has muddled the issue further as he and Republican leaders in Congress have offered differing timetables for when a Republican alternative might be unveiled, underscoring again how difficult it can be to push through an agenda even for a party that controls all the levers of government.
The origin story of the "repeal and replace" mantra is also a reminder of how pivotal strategic messaging has been throughout the health care debate. It has produced some of the more memorable political lines in recent years, from "death panels" to "If you like your health plan, you can keep your health plan" to "Obamacare" itself. After Republicans began throwing that term around as a pejorative, Mr. Obama embraced it.
Even before landing on "repeal and replace," Republicans scorched Democrats with buzzy phrases. In his book "The Long Game," Mr. McConnell recounted how he instructed his legislative experts to identify special provisions that had been added to the health bill to win over wavering Democrats.
His communications staff would then "brand" these legislative sweeteners with catchy but disparaging nicknames to build opposition and public distrust for the law. The result: the "Louisiana Purchase," "Gator Aid" and the memorable "Cornhusker Kickback," to tarnish provisions inserted to woo senators from Louisiana, Florida and Nebraska.
"In some ways, we were enjoying ourselves," Mr. McConnell acknowledged in his book.
The same communication strategists who originated those terms were brainstorming on March 22, 2010, while Mr. Holmes jotted ideas on a notecard. When he hit on "repeal and replace," the McConnell team decided it had what it needed. The big question was whether they could get lawmakers to embrace it. That answer would come quickly.
"I think the slogan will be 'repeal and replace,' 'repeal and replace,'" Mr. McConnell told reporters the next day. "No one that I know in the Republican conference in the Senate believes that no action is appropriate."
Mr. Holmes said a turning point came shortly after, when Representative Mike Pence of Indiana, who was then in charge of political messaging for House Republicans, and is now the vice president-elect, latched on to the phrase. That caused conservative resistance to the "replace" aspect of the debate to evaporate.
Mr. Holmes acknowledged that he had to create only the phrase, not the actual replacement.
"I don't do policy," he said with a laugh.
But Republican lawmakers and leaders of the new administration do have to do policy. And they may need to do it fast if they are going to assure Americans that they intend to fulfill their seven-year-old promise to not just repeal the law, but also replace it.
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PHOTOS: Senate Minority Leader Mitch McConnell and Representative Mike Pence of Indiana entering a meeting to discuss health care legislation in 2010. A note card from that meeting made "repeal and replace" a catchphrase for their strategy. (PHOTOGRAPH BY LUKE SHARRETT/THE NEW YORK TIMES)
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(Taking Note)
June 13, 2012 Wednesday
Uncertainty and Health Insurance Reform
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 369 words
HIGHLIGHT: Republicans love to kvetch about "uncertainty," except when they're causing it.
Mitt Romney said on the campaign trail in Florida yesterday that President Obama's health care reform law is hurting small businesses and that Mr. Obama is oblivious to the problem. "You have to scratch your head about that," Mr. Romney said.
Well, gosh, yes you do. Or at least you would if it were true.
As Brad DeLong reported on his blog, Mr. Romney's comment was "based on a local interview Obama gave in Iowa, in which the president was told by a reporter that a local company had closed and was moving jobs to Wisconsin because of Obamacare." Mr. Obama was incredulous, and that, I suppose, was the source of Mr. Romney's head scratching.
It turns out, however, that the company, Nemschoff Chairs, which makes furniture for waiting rooms, did not close because of health care reform. "We never said health care reform is the reason we're closing and consolidating that operation," Mark Schurman, a spokesman for Nemschoff's parent company told The Washington Post's Greg Sargent. "The issue is not the administration's proposed reform. The issue is there is no certainty as to what reform is going to look like."
Mr. Schurman cited the pending decision from the Supreme Court regarding the reform act's constitutionality. "Were there no ongoing debate there would be no uncertainty," he said.
Mr. Schurman raises an important point - other than Mr. Romney's habit of neglecting the truth.
Republicans love to kvetch about "uncertainty" - employers' uncertainty about the economy, for instance. On his blog recently, Paul Krugman took apart a research paper purportedly showing that "policy uncertainty" is restraining the economy. And House Speaker John Boehner has claimed that uncertainty over the future of the Bush tax cuts is hurting business.
About the only "uncertainty" they don't talk about is the status of health care reform.
That's because this particular uncertainty was entirely manufactured by Republicans - who began plotting to undo the Affordable Care Act by re-legislating it in the courts before the ink was dry on Mr. Obama's signature.
Opinion Report: Serial Bailouts
Shooting at Laws in Ads (Literally)
'Washington Doesn't Get Us'
Healthcare: What Might Have Been
Opinion Report: Crack and Cocaine
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(Taking Note)
March 27, 2015 Friday
Budget Grandstanding in the Senate
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 265 words
HIGHLIGHT: Senate Republicans have produced a budget that repeals the Affordable Care Act, guts Medicare, and gives a tax break to the rich.
The Republican Senate caucus - long one of the most irresponsible, ideologically blinkered and right-wing in history - spent last night producing its first budget. I almost thought it was a joke. There were plenty of fools and foolishness involved in this nonsense, but it's not April 1 yet.
The budget repeals President Obama's health reform law (because, of course, it's working pretty well and helping people who don't send large checks to the GOP).
It guts Medicare and turns it into a voucher-driven private insurance program (a huge gift to the health-care oligopoly and a crushing burden for the elderly); cuts back even farther on the pittance that Republicans in Congress are willing to give to the poor through Medicaid and food stamps; and - of course - provides a nice tax break to the highest-paid Americans, who don't need or deserve a tax break.
This budget, which drew not one Democratic vote, is extremely unlikely to become law. Mostly, it was driven by political grandstanding and by the strange belief among many Senate Republicans that they are qualified to be President. As Politico pointed out, the budget debate dissolved at one point into a contest among some of the most annoying armchair hawks in the Senate over who has the biggest swagger when it comes to national security and defense spending.
Watching Senators Marco Rubio and Ted Cruz act as though they have the slightest idea how to manage American foreign policy and the military is a reminder that it will be a very long 20 months until the election, with not much in the way of happy endings to look forward to.
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November 25, 2015 Wednesday
Late Edition - Final
Rise in Early Cancer Detection in Young Women Is Linked to Affordable Care Act
BYLINE: By SABRINA TAVERNISE
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 565 words
WASHINGTON -- Cancer researchers say there has been a substantial increase in women under the age of 26 who have received a diagnosis of early-stage cervical cancer, a pattern that they say is most likely an effect of the Affordable Care Act.
Starting in 2010, a provision of the health law allowed dependents to stay on their parents' health insurance until age 26. The number of uninsured young adults fell substantially in the years that followed. The share of 19- to 25-year-olds without health insurance declined to 21 percent in the first quarter of 2014 from 34 percent in 2010 -- a decrease of about four million people, federal data show.
Researchers from the American Cancer Society wanted to examine whether the expansion of health insurance among young American women was leading to more early-stage diagnoses. Early diagnosis improves the prospects for survival because treatment is more effective and the chance of remission is higher. It also bolsters women's chances for preserving their fertility during treatment. And women with health insurance are far more likely to get a screening that can identify cancer early.
Researchers used the National Cancer Data Base, a hospital-based registry of about 70 percent of all cancer cases in the United States. They compared diagnoses for women ages 21 to 25 who had cervical cancer with those for women ages 26 to 34, before and after the health law provision began in 2010. Early-stage diagnoses rose substantially among the younger group -- the one covered by the law -- and stayed flat among the older group.
About 79 percent of the younger group had an early-stage diagnosis in 2011-12, up from about 71 percent in 2007-09. For the older group, the percentage dropped to 71 percent from 73 percent, a change that is not statistically meaningful.
The study was not aimed at proving that the change was a direct result of the law. But the size of the database, and the fact that the share of young women with health insurance had increased so substantially, led researchers to conclude that the law was having an effect. (Pap tests are a part of most routine medical checkups for young women.)
''It's a very remarkable finding, actually,'' said Dr. Ahmedin Jemal, one of the researchers. ''You see the effect of the A.C.A. on the cancer outcomes.''
The effect for younger women looked even stronger when analyzed by year. About 84 percent of the younger group had early-stage diagnoses in 2011, compared with 68 percent in 2009. Early-stage diagnoses dropped to 72 percent of the group in 2012, a drop that Dr. Jemal said was typical during increases in screenings, because many of the early-stage cases have already been detected.
For several years, researchers have been trying to test whether the law is working to improve health, but isolating its effects has been tricky. A study this spring found that the number of new diabetes cases identified among poor Americans had surged in states that embraced the Affordable Care Act, but not in states that had not.
Since November 2009, the American College of Obstetricians and Gynecologists has recommended that cervical cancer screening begin at age 21, the only cancer screening recommendation for that age group. Dr. Jemal said that change made it impossible to compare the total number of women who got screened before and after the health care law came into effect.
URL: http://www.nytimes.com/2015/11/25/health/rise-in-early-cervical-cancer-detection-is-linked-to-affordable-care-act.html
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July 17, 2013 Wednesday
Policy Impact and Red Herrings
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 513 words
HIGHLIGHT: Assessing government policy before and after changes are put into effect is the best way to assess that policy’s impact, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Red herrings are frequently inserted into policy discussions but can be readily identified as long as we remember a simple truth about public policy impact.
The impact of public policy on an economic outcome like employment is, by definition, the difference between employment with the policy in place and what employment would have been under an alternative "baseline" policy. Policy impact quantifies how things are different as a consequence of the policy.
Consider these statements:
"The Affordable Care Act will not reduce full-time employment because workers understand that full-time employment is the path to career advancement" (see my previous post).
"Unemployment insurance does not reduce employment because Americans fundamentally want to work and provide for themselves" (see, for example, this commentary on gawker.com)
These are all examples of red herrings, irrelevant statements that are attached to hypotheses.
Take the full-time employment example. It may be true that full-time employment is the path to career advancement, but that is hardly relevant to the Affordable Care Act as long as we assume that full-time employment would be that path regardless of whether we have that law.
That is, lots of people will choose full-time employment because of the career opportunities it provides, but they are counted as full-time employed under the policy and as full-time employed under the baseline policy (say, continuing as if the act had never become law). A policy impact estimate, by definition, counts only those for whom career advancement does not trump their decision to be in a full-time position.
As I explained in that an earlier post, the Affordable Care Act introduces funds and insurance opportunities for part-time employees that will be unavailable to most full-time employees. As long as there are more than zero people whose full-time vs. part-time work decision depends on funds or insurance, there is the potential for policy impact.
In my second example, it may be true that most people want to work and provide for themselves. But I assume motivation to work is the same regardless of whether unemployment benefits are paid for, say, 99 nine weeks or 26. What's different between the 99-week policy and the 26-week baseline are the circumstances in which people find themselves.
As long as motivation is not the sole factor determining employment, there is the potential for unemployment insurance to have a policy impact, even in a country in which the people are fundamentally hard-working.
Nobody expects a government program to make everything different. So policy analysis is particularly useful in subtracting out the outcomes that would occur regardless of policy measures.
Yes, the Sequester Is Affecting the Job Market
Behind the Disappointing Jobs Report
Working Parents, Wanting Fewer Hours
How One Month's Jobless Fare a Month Later
Implications for Monetary Policy
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March 31, 2017 Friday
Late Edition - Final
Kansas Governor Vetoes a Medicaid Expansion, Setting the Stage for a Showdown
BYLINE: By ABBY GOODNOUGH and MITCH SMITH
SECTION: Section A; Column 0; National Desk; Pg. 10
LENGTH: 808 words
Gov. Sam Brownback of Kansas vetoed a bill on Thursday that would have expanded Medicaid in his state, setting up a potential showdown next week with a Legislature that, while heavily Republican, has come to favor extending the largely free health coverage to as many as 180,000 additional poor adults.
Although the bill was easily approved in both chambers of the Legislature, supporters would need to muster three additional votes in the House and two in the Senate to override the veto by Mr. Brownback, a conservative Republican.
After the House briefly debated an override on Thursday, the measure was put aside, probably until at least next week. Supporters were hoping to mobilize hundreds of residents who would benefit from Medicaid expansion, as well as hospital executives, clergy members and others who back the measure, to lobby specific lawmakers over the weekend.
''Our plan is to make sure their phones are ringing off the hook,'' said David Jordan, executive director of Alliance for a Healthy Kansas, an advocacy group.
Republican lawmakers in Kansas were initially solidly opposed to expanding Medicaid under the Affordable Care Act, commonly known as Obamacare. But many softened their positions over the last year or so, particularly influenced by the financial struggles of the state's small rural hospitals. Momentum grew after several Democrats and moderate Republicans picked up legislative seats in the elections last fall, although the leaders of both legislative chambers remain opposed to any expansion.
In his veto message, Mr. Brownback said the cost of expanding Medicaid would be ''irresponsible and unsustainable,'' citing other states where Medicaid enrollment grew far more than expected after they expanded the program. The expansion effort comes in the midst of a budget crisis that has roiled Kansas for years.
Passage of the Medicaid bill was another sign of revolt against Mr. Brownback, whose tax-cutting regimen led to years of missed revenue forecasts and budget cuts. Last month, House lawmakers voted to override Mr. Brownback's veto of a bill that would have raised taxes, but the Senate upheld the veto.
Lawmakers face projected budget deficits of more than $280 million for the current fiscal year and more than $510 million for the next year. They also must address a recent state Supreme Court ruling that found public school funding to be unconstitutionally low.
In emotional debate on Thursday, less than a week after President Trump and Republicans in Congress pulled legislation to repeal the Affordable Care Act, Kansas House members who support Medicaid expansion framed the issue as a moral imperative that could save lives and stave off hospital closings in beleaguered towns.
''I am appalled with the letter that was read from the governor,'' Representative Larry Hibbard, a Republican, said on the House floor, referring to Mr. Brownback's veto message. Mr. Hibbard said he worried that some rural hospitals in his district in southeastern Kansas could close without Medicaid expansion, hurting patients and imperiling the future of those towns.
''The lack of compassion toward this issue just blows my mind,'' Mr. Hibbard said. ''This is a life-and-death issue.''
Opponents often cited concerns about the state's broader budget challenges.
Representative Chuck Weber, a Republican from Wichita, said expanding Medicaid would make it harder for those already covered by the program to receive care.
Another Republican, Representative Daniel Hawkins of Wichita, noted the uncertainty surrounding the Affordable Care Act, a concern also raised by Mr. Brownback.
Under the Affordable Care Act, the federal government currently pays 95 percent of the costs of expanding Medicaid, eventually dropping to 90 percent but never less. But the Republican repeal bill would have made it all but impossible for states to keep that large federal match.
All but 19 states have expanded Medicaid to cover adults with incomes up to 138 percent of the poverty level -- $16,400 for a single person. Voters in Maine will decide whether to do so in a ballot referendum this fall, and Democrats in a few other states are renewing pushes to expand the program now that the Republican plan to repeal the health law has been stalled.
But at the same time, some Republican governors are discussing adding work requirements for their Medicaid populations or even scaling back enrollment now that the Trump administration has promised states more flexibility in determining benefits and eligibility.
''The next hospital to fail could be in your community or your district,'' said one supporter of the expansion, Representative Jim Kelly, a Republican from Independence, where the only hospital closed in 2015. ''And I will tell you from experience, real-life experience: It's not a pretty picture.''
URL: http://www.nytimes.com/2017/03/30/us/medicaid-kansas-brownback-override-legislature.html
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The New York Times
December 16, 2015 Wednesday
Late Edition - Final
Parties Reach House Deal on Spending and Tax Breaks
BYLINE: By DAVID M. HERSZENHORN and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 24
LENGTH: 991 words
WASHINGTON -- Republican and Democratic negotiators in the House clinched a deal late Tuesday on a $1.1 trillion spending bill and a huge package of tax breaks.
Legislative drafters, racing a midnight deadline, met the time limit for issuing the tax package but apparently missed it for the spending bill. That could push back a vote on the House floor by one day, until Friday.
The late-hour tension emphasized the deep disagreements over an array of policy provisions that have left weeks of negotiations tinged with acrimony. Since the Republicans took back control of the House in 2011, a majority in the party has routinely opposed compromise budget and spending measures, forcing party leaders to rely on Democrats for votes to clear the bills. All signs indicate that the same dynamic is playing out now.
But the House Democratic leader, Representative Nancy Pelosi of California, has voiced angry opposition to the huge package of tax breaks, saying it would unfairly benefit big business. And even Tuesday night, some Democrats in the House leadership said Ms. Pelosi was on the verge of turning against the omnibus spending measure because of her opposition to a Republican provision that would lift the 40-year ban on exports of crude oil from the United States.
Republican congressional leaders and the White House reached a budget accord in late October that set top-line spending levels for 2016 and 2017. Throughout Tuesday, major components of the spending legislation appeared to be falling into place, including a tentative agreement to alter major provisions of the Affordable Care Act, delaying a planned tax on high-cost health insurance plans and suspending a tax on medical devices for two years.
Lawmakers also said the package would include the reauthorization and expansion of aid for emergency workers suffering from ailments related to the Sept. 11, 2001, terrorist attacks in New York.
Paul D. Ryan has gained momentum in his early weeks as speaker, clearing a major highway bill and an important education measure. But the omnibus spending bill, needed to keep the government functioning, presented a particular challenge given the Obama administration's opposition to numerous policy prescriptions that Republicans wanted to attach to the must-pass bill.
There were indications late Tuesday that Mr. Ryan and Republicans had been forced to give substantial ground, and that the spending measure would not include provisions tightening restrictions on Syrian and Iraqi refugees. A stand-alone measure to tighten those restrictions passed overwhelmingly in the House, but the White House and Senate Democrats said they would block it.
And while Mr. Ryan has won plaudits from his rank and file for running a more inclusive House, the late rush to finish the spending deal seemed likely to test him on that front.
The question of delaying important provisions of the Affordable Care Act provided a surprising area of common ground -- among Republicans who have sought to dismantle President Obama's signature health care law, and Democrats who had reservations about a tax on generous health plans. The White House and many economists have defended the ''Cadillac tax'' on high-cost employer-sponsored health plans as a way to reduce health costs and make the health care system more efficient.
But lawmakers said they had tentatively agreed to delay the tax, originally scheduled to take effect in 2018, by two years. Labor unions strenuously opposed the tax, saying it could lead to reductions in health benefits prized by their members.
Republicans said the package would delay what they see as harmful health-related taxes and could set a precedent for efforts to undo other provisions of the health care law.
''We have a real opportunity to significantly reduce Obamacare's tax burdens,'' said Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee.
It also appeared that manufacturers of medical devices were on the threshold of a victory in their campaign to roll back an excise tax on many of their products. Under the tentative agreement, the device tax, which took effect in 2013, would be suspended through 2017, congressional aides said.
Republicans said the device tax discouraged the development and sales of innovative, lifesaving medical technology. Some Democrats from states with thriving medical technology companies agreed. The tax package also includes a one-year delay in a separate annual fee on health insurance providers, one of a number of taxes that help offset the costs of expanding coverage under the Affordable Care Act.
Insurance companies say this levy, known as the health insurance tax, is passed on to consumers, drives up premiums and imposes a financial burden on many families and small businesses.
Republicans said the package would delay what they see as harmful ''Obamacare taxes'' and could set a precedent for efforts to undo other provisions of the health care law, which was adopted in 2010 without any Republican votes.
The emerging agreement would permanently extend a popular business tax credit for research, one of many tax breaks that have been repeatedly renewed on a temporary basis. It would also continue a tax deduction for teachers who spend their own money for books, supplies and computer equipment used in the classroom, and a separate deduction for state and local sales taxes.
There had been widespread support for a stand-alone measure to help the 9/11 responders, but congressional leaders were never quite able to push it across the finish line. While lawmakers from the New York area were strong advocates for the bill, it also had the forceful backing of Jon Stewart, the former host of ''The Daily Show,'' who made repeated trips to the Capitol to push for it.
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URL: http://www.nytimes.com/2015/12/16/us/politics/congress-9-11-emergency-workers-zadroga-act.html
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March 16, 2017 Thursday
Late Edition - Final
One Certainty in Health Bill: Tax Cuts for Wealthy
BYLINE: By ALAN RAPPEPORT
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 955 words
WASHINGTON -- The House Republicans' plan to replace the Affordable Care Act is messy and confusing. No one is sure exactly how Americans will be affected and how much more health insurance will cost them.
But there are two certainties. Their health care plan provides a tax cut for the wealthiest Americans. And it will make it easier for Republicans to pass more tax cuts this year. It could also be viewed by some people as a break from some of the populist campaign promises President Trump made to lift up the country's ''forgotten men and women.''
The Congressional Budget Office analysis of the Republican plan released this week revealed the full scope of the windfall that the legislation would bring. It offers billions of dollars' worth of tax cuts to health insurers, pharmaceutical companies, investors and even tanning salon operators. The cuts amount to nearly $1 trillion over a decade. The beneficiaries would be the richest Americans who for years have complained that the Affordable Care Act unfairly burdened them with the responsibility of subsidizing insurance for the poor.
The repeal of the Affordable Care Act's taxes is necessary for Republicans to move forward with an even more ambitious part of their agenda: tax reform. ''Doing this first shrinks the amount of revenue they are going to have to raise to make their tax bill add up,'' said Howard Gleckman, a fellow at the Tax Policy Center.
In order to get any tax overhaul through the Senate with a simple majority, the tax bill under Senate rules can't increase the federal deficit. Since the health care bill would cut the federal deficit it makes it easier to come back later and pass more tax cuts.
''This dramatically helps us for tax reform,'' Speaker Paul D. Ryan said on Fox News last week.
The Republican's proposed health care legislation has met the inevitable backlash by Democrats. ''This scheme will give billions upon billions of dollars in tax cuts to the most fortunate at the expense of the most vulnerable,'' said Senator Ron Wyden, the Oregon Democrat who is the ranking member of the Senate Finance Committee. ''It clearly and directly breaks the 'Mnuchin rule' promise that there would be no absolute tax cut for the wealthy, period.''
Steven T. Mnuchin, Mr. Trump's Treasury secretary, gave assurances as recently as last month that ''there would be no absolute tax cut for the upper class.'' During Mr. Mnuchin's Senate confirmation hearing, Democrats referred to the promise as the ''Mnuchin rule.''
That tenet, critics say, has now been violated. And Speaker Ryan's strategy has put some Republicans in an uncomfortable position of defending tax cuts for the rich after a year in which populist fervor spurred by income inequality upended American politics.
Whether the legislation, if passed, hurts Republicans in next year's midterm elections remains to be seen. Democrats are already preparing to argue that Republicans are out of touch with working Americans, while Republicans insist that they are following through on their promises.
Republicans may have the harder time of it. A study by the Tax Policy Center, a nonpartisan research group, found that when the bill would take full effect in 2022, 40 percent of the benefits from the tax cuts would go to the richest one percent of the country. Those households would receive an average tax cut of $37,000, or 2.1 percent of their incomes. People in the lowest income bracket would get an average tax cut of $150, an amount that is just 0.9 percent of their earnings.
An analysis by The Upshot found that the provisions of the proposed health legislation could also be particularly painful to rural Americans, who do not benefit from competitive marketplaces for doctors, hospitals and insurers. Voters who supported Mr. Trump would be hit the hardest, receiving disproportionately small tax credits.
Companies and investors would see big benefits too. The Republicans' plan removes $145 billion in taxes on health insurers, $158 billion on investment income for top earners, $25 billion on drug companies and $20 billion medical device companies.
While businesses in the health care sector have so far been skeptical of the health plan, the bill also comes with some sweeteners. One that has drawn particular outrage among defenders of the Affordable Care Act is a provision that would give health insurers greater incentives to give their executives raises by eliminating the health plan's cap on compensation deductions.
Some of the gains for the most well off will come at the expense of the vulnerable. Health insurers will be allowed to once again increase premiums on older customers who are more likely to require medical services. Over the next 10 years, $880 billion in federal funding for Medicaid would be cut.
Democrats have seized on the tax cuts as evidence that Mr. Trump, who is aggressively pitching the health plan, is selling out his base and breaking campaign promises that he made to working class Americans. At one point during the campaign Mr. Trump said that the rich should pay more in taxes and that he would gladly do so.
''This is the type of class warfare that Democrats like to stir up,'' said Ryan Williams, a Republican strategist and former spokesman for Mitt Romney, who made the case that tax reform would be the centerpiece of Mr. Trump's legacy on taxes.
For its part, the White House so far appears undeterred by accusations that it is lavishing tax breaks on the rich.
''We promised at the outset that we were going to repeal all of the taxes,'' Mick Mulvaney, the White House budget director, said on MSNBC on Tuesday, referring to the Affordable Care Act.
He added, ''Who cares if somebody else benefits?''
URL: http://www.nytimes.com/2017/03/15/us/politics/obamacare-repeal-tax-cuts.html
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September 18, 2013 Wednesday
Late Edition - Final
Several States Undercutting Health Care Enrollment
BYLINE: By LIZETTE ALVAREZ and ROBERT PEAR; Lizette Alvarez reported from Miami, and Robert Pear from Washington.
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 1048 words
MIAMI -- As many states prepare to introduce a linchpin of the 2010 health care law -- the insurance exchanges designed to make health care more affordable -- a handful of others are taking the opposite tack: They are complicating enrollment efforts and limiting information about the new program.
Chief among them is Florida, where Gov. Rick Scott and the Republican-dominated Legislature have made it more difficult for Floridians to obtain the cheapest insurance rates under the exchange and to get help from specially trained outreach counselors.
Missouri and Ohio, two other states troubled by the Affordable Care Act, have also moved to undercut the law and its insurance exchanges, set to open on Oct. 1. In Georgia, the state insurance commissioner, Ralph T. Hudgens, has said he will do ''everything in our power to be an obstructionist.''
Alarmed by the resistance, the secretary of health and human services, Kathleen Sebelius, and the Obama administration are intensifying their efforts to win public support for the exchanges in Florida and elsewhere and are confronting their critics head on.
On Tuesday, Ms. Sebelius capped a three-city visit to Florida -- home to the country's second largest uninsured population -- with sharp words about the state's unwillingness to embrace the law. She will do the same in Missouri later this week.
''It's unfortunate that keeping information from people seems to be something of a pattern here in the state,'' Ms. Sebelius said at a news conference in Miami, referring to restrictions on outreach counselors.
The online exchanges are designed to offer a variety of insurance plans at subsidized prices and are meant to make health care more affordable to lower-income people who do not have insurance. Outreach counselors, known as navigators, provide information about the plans and help enroll applicants.
Ms. Sebelius also criticized Florida's rejection of $50 billion in federal money over 10 years to expand Medicaid, its concerns about privacy issues, which she said were unfounded, and its sudden unwillingness to grapple with insurance rates.
Even among states hostile to the law, Florida became an outlier this year when it passed a bill removing for two years the state insurance commissioner's ability to approve insurance rates for new health plans, she said. This leaves Floridians vulnerable to higher rates at a time when the new health plans will be introduced.
In other states, insurance commissioners used the law to obtain better deals for consumers.
''To have the Florida Legislature pass a bill that for two years -- 2014 and 2015 -- removes rate-review authority really puts Florida consumers at great risk,'' Ms. Sebelius said, adding, ''No one else has done that.''
Ms. Sebelius's criticism is unlikely to inspire cooperation in Florida or in the other states that vigorously oppose the law. Mr. Scott has been one of the law's fiercest opponents, despite his decision to accept the $50 billion for Medicaid expansion. But the Florida House blocked that effort this year while Mr. Scott sat mostly on the sidelines, failing to lobby for the expansion, lawmakers said. The state also chose not to run its own health care exchange, leaving it to the federal government.
Democrats said Mr. Scott and Republican lawmakers continued to throw up roadblocks.
Last week, Florida's deputy health secretary ordered county health facilities to bar navigators, or outreach counselors. The health department said it was following established policy: All outside groups are prohibited from using county health property to conduct nonstate business. Brochures, though, will be made available, according to a statement. No written requests for space have been made by navigators, a spokesman said.
County health offices are important in the campaign to reach potential applicants because they deal mostly with lower-income people who may not be insured.
And on Monday, in a letter to the top Republican and Democrat in Congress, Mr. Scott raised concerns about privacy, saying that navigators and others involved in the health care effort could use applicant information improperly. Attorneys general from 13 states have expressed similar worries about the release of financial and medical information -- be it intentional or accidental.
Saying that Florida was ''ground zero'' in the Obama administration's campaign to enroll people, Mr. Scott asked House Speaker John A. Boehner and the Senate majority leader, Harry Reid, ''to thoroughly review what privacy rules and safeguards are in place.''
''Floridians should not have to exchange their privacy for insurance,'' Mr. Scott wrote.
Ms. Sebelius said on Tuesday that she appreciated the governor's concerns but that her office, which oversees Medicare, is used to dealing with privacy issues.
''I can guarantee you we take that very, very seriously, which is why nobody will be collecting personal health information at all at any point along the way,'' she said. ''Verifying, yes; storing it, no.''
Florida is not the only state complicating the Obama administration's efforts to roll out the new exchanges.
A Missouri law adopted this year requires the licensing of navigators and also restricts their activities. Without that license, the Missouri law says, navigators cannot ''provide advice concerning the benefits, terms and features of a particular health plan'' or ''advise consumers about which health plan to choose.''
Ohio has adopted a similar law, stating that navigators can distribute some information but cannot recommend a plan or offer advice about benefits in a particular plan.
In Georgia, the insurance commissioner, Mr. Hudgens, said his ''job is to protect consumers.'' To that end, Georgia mandates that health insurance counselors be licensed to become navigators, a process that requires criminal background checks and fingerprinting of applicants.
For Democrats, the new state laws and rules are just another way to throw up obstacles to try to defeat the Affordable Care Act.
''They couldn't beat Obamacare in Congress, where they've tried 41 times to repeal it, they couldn't beat it in the Supreme Court, so they are trying death by a thousand cuts,'' said Representative Debbie Wasserman Schultz, a Florida Democrat and chairwoman of the Democratic National Committee.
URL: http://www.nytimes.com/2013/09/18/us/florida-among-states-undercutting-health-care-enrollment.html
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October 31, 2013 Thursday
Late Edition - Final
Contrite White House Spurns Health Law's Critics
BYLINE: By MICHAEL D. SHEAR and ROBERT PEAR; Michael D. Shear reported from Boston, and Robert Pear from Washington.
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 1173 words
BOSTON -- The White House on Wednesday blended expressions of contrition for the troubled rollout of its health care law with an aggressive rejection of Republican criticism of it, as the administration sought a political strategy to blunt the fallout from weeks of technical failures and negative coverage.
While Kathleen Sebelius, the secretary of health and human services, apologized profusely during a politically charged hearing on Capitol Hill, President Obama traveled to Massachusetts to argue forcefully that the Affordable Care Act will eventually be just as successful as the similar plan pioneered by Mitt Romney, his onetime rival and a former governor of the state.
Speaking in the historic Faneuil Hall, where Mr. Romney signed the Massachusetts plan into law, the president also took ''full responsibility'' for the malfunctioning health care website and promised to fix it. But he pledged to ''grind it out'' over the weeks and months ahead to ensure the law's success and prove its Republican critics wrong.
''We are going to see this through,'' Mr. Obama vowed, pounding his fist on the podium as the audience roared with approval.
The dual messages from Mr. Obama and Ms. Sebelius over the course of the day reflect a recognition by officials inside the White House that while apologies are in order, the administration cannot let Republicans expand concerns about the HealthCare.gov website into a broader indictment of the law.
Senior advisers to the president said they understood that the bungled rollout of the insurance marketplace has given Republicans another opportunity to litigate the political case against the health care law. But they said they viewed the weeks ahead as a period of inevitable improvement that will vindicate their position.
''The weight of that momentum will have a positive impact,'' one senior administration official said, requesting anonymity to talk about White House strategy planning. ''Really it's about blocking and tackling and getting that work done.''
With Republicans showing no sign of backing off, the challenge for Mr. Obama and Democrats in the months to come will be to deflect political attacks that unfairly demonize the health care law while acknowledging its shortcomings. Achieving that nuance could prove tricky for an administration whose top health official, Ms. Sebelius, on Wednesday called the rollout of the online insurance marketplace a ''debacle.''
Ms. Sebelius told lawmakers on the House Energy and Commerce Committee that she was as surprised as anyone when the website collapsed on Oct. 1 under pressure from millions of users and was crippled by technical problems in subsequent days. While she was aware of the risks in a big information technology project, she said, ''no one indicated that this could possibly go this wrong.''
Ms. Sebelius told the committee: ''Hold me accountable for the debacle. I'm responsible.''
The shift in strategy from the White House comes as new challenges emerge for the law. The problem-plagued website crashed again just before Ms. Sebelius began testifying in front of a skeptical congressional panel. And officials acknowledged that the federal insurance marketplace for small businesses, which had already been delayed a month from Oct. 1, would not open until the end of November.
In three and a half grueling hours of testimony, Ms. Sebelius gamely defended the troubled rollout of the law and apologized for what had gone wrong. But nothing she said could overcome the stark message displayed on a large video screen showing a page from HealthCare.gov: ''The system is down at the moment. We are experiencing technical difficulties and hope to have them resolved soon. Please try again later.''
Representative Mike Rogers, Republican of Michigan, said the administration had not properly tested the security of the insurance website, which receives financial information on consumers seeking subsidies to help pay their premiums.
Mr. Rogers read from a government memo that said security controls for the federal exchange had not been fully tested as of Sept. 27. This creates a potentially ''high risk'' for the exchange, said the memo, from the Centers for Medicare and Medicaid Services. The memo said that security controls would be ''completely tested within the next six months.''
Republicans continued to accuse Mr. Obama of lying to the American people when he said repeatedly over the past four years that people who had a health insurance plan they liked could keep it, regardless of the changes brought on by the Affordable Care Act. Lawmakers grilled Ms. Sebelius on why insurance companies are canceling policies for thousands of people across the country.
Representative Fred Upton, Republican of Michigan and chairman of the committee, said: ''There are millions of Americans coast to coast who no doubt believed the president's repeated promise that if they liked their plan, they'd be able to keep it. They are now receiving termination notices.''
Ms. Sebelius tried, with little success, to allay concerns about those notices, which have been sent to hundreds of thousands of consumers stating that their individual insurance policies would soon be terminated because they did not comply with new standards under the Affordable Care Act. She said the cancellation of some policies was a justifiable byproduct of the 2010 health law.
But in Massachusetts, Mr. Obama for the first time admitted that some people who have had what he called ''substandard'' insurance plans may have to choose another one now that the Affordable Care Act has gone into effect. He accused lawmakers in Washington of distorting that fact by failing to mention that the new plans they have will be more comprehensive and often come with cheaper premiums.
''If you leave that stuff out, you are being grossly misleading, to say the least,'' Mr. Obama said.
Mr. Obama made comparisons between the rollout of the national health care law and the problems experienced in the days after the Medicare prescription drug program went into effect in 2006. In his remarks, the president said that when those problems occurred, ''Democrats worked with Republicans to make it work.''
The president also repeatedly invoked Mr. Romney's name as evidence of the bipartisan spirit that led to the passage and implementation of the health care law in Massachusetts. He said Mr. Romney ''did the right thing on health care'' in the state.
But Mr. Romney did not return the favor, issuing a statement hours before the president's speech that repeated his longstanding criticism of the national law.
''Nothing has changed my view that a plan crafted to fit the unique circumstances of a single state should not be grafted onto the entire country,'' Mr. Romney said. ''Health reform is best crafted by states with bipartisan support and input from its employers, as we did, without raising taxes, and by carefully phasing it in to avoid the type of disruptions we are seeing nationally.''
White House aides said they did not ask Mr. Romney to attend the speech.
URL: http://www.nytimes.com/2013/10/31/us/politics/obama-defends-health-law-in-Boston-speech.html
LOAD-DATE: October 31, 2013
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GRAPHIC: PHOTOS: Kathleen Sebelius, the health and human services secretary, spoke to a House committee for more than three hours Wednesday. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)
Outside Faneuil Hall in Boston, where President Obama spoke, a supporter of the health care law expressed her sentiments. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES) GRAPHICS: Why Some Can't Keep the Plan They Like: Despite repeated assertions by President Obama that people who like their health insurance will able to keep it under the new health care law, many people who bought insurance on their own -- a small fraction of the insurance market -- will have to buy new plans.
Why Rates Are Increasing for Some People (Sources: Jonathan Gruber, Massachusetts Institute of Technology
Darshak Sanghavi, Brookings Institution
Kaiser Family Foundation
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November 18, 2013 Monday
Another Website, Another Problem for Obama
BYLINE: MICHAEL D. SHEAR
SECTION: US; politics
LENGTH: 581 words
HIGHLIGHT: Some supporters who tried to log in to hear the president defend his health care law could not hear him because the website of the group behind the call failed to work for them.
WASHINGTON - Some supporters who tried to log in to hear President Obama defend his embattled health care law on Monday night were unable to hear him because the website of the group behind the call, Organizing for Action, failed to work for them.
The website problems were an inconvenient moment for a president who has spent the last six weeks trying to explain the failure of HealthCare.gov, the online marketplace for Mr. Obama's Affordable Care Act.
The event on Monday was intended to offer Mr. Obama's most ardent supporters a chance to hear directly from him. It was the latest conference call to be hosted by Organizing for Action, the nonprofit group that grew out of the president's 2012 campaign organization.
"I want to cut through the noise and talk with you directly about where we're headed in the fight for change," Mr. Obama had said in one of many emails sent to supporters over the past several days. The emails urged supporters to log onto an Organizing for Action website at 8:15 p.m. to listen to the president's remarks.
Mr. Obama told those who could hear that there had been "a lot of misinformation" about his health care plan and noted that nearly a half-million people had signed up for Medicaid or for new insurance despite the problems with the health care website.
"I am confident that by the end of this month, it's going to be functioning for the vast majority of folks," Mr. Obama said. "Despite all the noise out there, despite all the criticism, despite all the setbacks, I've never lost faith in our ability to get this done."
But many people who logged in said they could not hear anything, with the website reporting "connection failure" over and over again. It was unclear how many people could listen to the call. An official with the group gave a New York Times reporter, who also could not hear anything on the website, a telephone number to call and listen in.
At the same time, a chat board on the website began filling up with messages:
"I can't hear any audio?"
"Is everyone getting the 'reconnecting' message?"
"I did refresh twice - still no sound."
"WHERES THE SOUND YO?"
One supporter pleaded, "Don't tell me there are troubles with this live event like there were with the Obamacare website!!!!!"
Organizing for Action officials said at the beginning of the call that more than 200,000 people had signed on to listen to the president. Katie Hogan, a spokeswoman for the group, said that technicians noticed a spike in traffic at the beginning of the call and that there was no indication that large numbers of people were unable to hear the president.
Ms. Hogan said the "vast majority" of those who logged in were able to listen in, and she pointed to the quick popularity of a Twitter hashtag - #ofacall - that was announced on the call as evidence.
Whether or not people could hear may not have mattered much.
"I CAN'T HEAR YOU, MR PRESIDENT, BUT I'M BEHIND YOU," one person wrote. "PLEASE STICK IT OUT WITH OBAMACARE. THE COUNTRY NEEDS IT ... AND YOU."
The glitch was at the very least inconvenient for a White House that has been struggling to combat the perception that it cannot get things done.
"Just like healthcare.gov, this site doesn't work either," another supporter said. "It is tougher and tougher to defend all of this mr president."
10 Questions for President Obama
Obama Selects Romney Adviser for Social Security Commission
Lawmakers Point Fingers Over Budget Deadlock
The Early Word: Escalating
The Early Word: Pre-Existing Conditions
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March 17, 2015 Tuesday
Late Edition - Final
Could Obama Bypass the Supreme Court?
BYLINE: By WILLIAM BAUDE.
William Baude, a contributing opinion writer, is an assistant professor of law at the University of Chicago.
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CHICAGO -- IT is time to talk about President Obama's contingency plan for health care. The Supreme Court heard oral arguments earlier this month in King v. Burwell, a case challenging the provision of tax credits on federal insurance exchanges. While the legal issues are dry lawyers' fare -- how to interpret several interconnected phrases of the Affordable Care Act -- the practical stakes are high. The government estimates that millions of Americans will be left without affordable health insurance if it loses.
While the administration may well prevail, it has expressed remarkable pessimism about its options if it does lose. The secretary of health and human services, Sylvia Mathews Burwell, wrote to Congress last month about the administration's lack of a contingency plan: ''We know of no administrative actions that could, and therefore we have no plans that would, undo the massive damage to our health care system that would be caused by an adverse decision.''
But luckily the Constitution supplies a contingency plan, even if the administration doesn't know it yet: If the administration loses in King, it can announce that it is complying with the Supreme Court's judgment -- but only with respect to the four plaintiffs who brought the suit.
This announcement would not defy a Supreme Court order, since the court has the formal power to order a remedy only for the four people actually before it. The administration would simply be refusing to extend the Supreme Court's reasoning to the millions of people who, like the plaintiffs, may be eligible for tax credits but, unlike the plaintiffs, did not sue.
To be sure, the government almost always agrees to extend Supreme Court decisions to all similarly situated people. In most cases, it would be pointless to try to limit a decision to the parties to the lawsuit. Each new person who was denied the benefit of the ruling could bring his own lawsuit, and the courts would simply rule the same way. Trying to limit the decision to the parties to the suit would just delay the inevitable.
But the King litigation is different, because almost everybody who is eligible for the tax credits is more than happy to get them. Most people who receive tax credits will never sue to challenge them. Lawsuits can be brought only by those with a personal stake, so in most cases the tax credits will never come before a court. The administration is therefore free to follow its own honest judgment about what the law requires.
This idea may seem radical, but it has a strong legal pedigree. Judicial authority, or jurisdiction, is case-specific and person-specific. That is true even of the Supreme Court, which the Constitution gives ''judicial power'' to decide ''cases'' and ''controversies.'' It is reaffirmed by Marbury v. Madison (1803), which affirmed the power of judicial review by relying on the Supreme Court's duty to decide ''particular cases.''
President Obama could also take a page from President Lincoln. In his first inaugural address, Lincoln discussed a recent Supreme Court decision about slavery. He forswore ''any assault upon the court,'' but stressed that ''the policy of the Government upon vital questions affecting the whole people'' ought not be ''irrevocably fixed'' by a single suit brought by only a few. He said that Supreme Court opinions were thus ''entitled to very high respect and consideration in all parallel cases'' but were ultimately limited to ''the parties to a suit as to the object of that suit.'' If the Obama administration thinks the stakes are high enough, it can take the same path.
There are legal wrinkles, of course. Lower courts have sometimes claimed legal authority to invalidate a regulation (which is at issue in this case) even for parties who aren't before the court. And some employers might be able to bring lawsuits that would call their employees' subsidies into question. But the administration has already raised legal defenses to those potential problems in other lawsuits and could press those defenses here, too.
The real obstacle to this contingency plan is not legal, but political. Invoking this constitutional prerogative forces the president to spend substantial political capital, and it is easier to shift the blame. That may be a broader pattern in modern politics. For instance, the administration has called on Congress to reduce unjust sentences even though the president could simply commute them on his own constitutional authority.
But we should not let the president avoid responsibility by abdicating his powers. If the administration believes that a Supreme Court loss would be egregious and disastrous, it ought to consider taking the political heat to limit it.
Should the administration lose this lawsuit, it will be quick to blame the court for the consequences. But the administration should instead decide whether it is willing to put its constitutional powers behind its words. If not, then it will deserve a share of its own blame.
URL: http://www.nytimes.com/2015/03/17/opinion/could-obama-bypass-the-supreme-court.html
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The New York Times
November 8, 2014 Saturday
Late Edition - Final
Health Care Reform Imperiled
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 20
LENGTH: 453 words
Will five Supreme Court justices eliminate essential health care subsidies for more than four million lower-income Americans, based on a contorted reading of four words?
It sounds inconceivable, but that would be the effect of a ruling in favor of the latest legal challenge to the Affordable Care Act. On Friday, the justices announced that they would hear that case, King v. Burwell, a dispute over the meaning of a single phrase -- ''established by the State'' -- in the 900-page health-care reform law.
The law, which has been under constant assault since its 2010 passage, has made health-care coverage newly available for between 8 and 11 million people this year alone.
This unprecedented achievement in social policy has improved, and surely saved, many lives. But, to the law's implacable opponents, it represents nothing more than an oppressive big-government program that must be stomped out.
The opponents lost before the Supreme Court in 2012 in an effort to kill the law on constitutional grounds. Now they are taking aim at the tax-credit subsidies that are central to the success of health reform.
Because one subsection of the law says these subsidies are available on an exchange ''established by the State,'' the plaintiffs claim there can be no subsidies for anyone living in the 36 states where the federal government established a health exchange after state officials did not.
It is a superficially simple argument, which most federal judges who have considered the claim have rejected. That is because it runs counter to the explicit purpose and structure of the Affordable Care Act. As everyone involved in the law's creation understood at the time, its success depends on making coverage both required and available to as many people as possible. As a Senate staff member told Vox.com recently, ''We certainly wanted every individual in every state, regardless of their federal or state exchange status, to receive the same subsidies.''
In cases where there is a dispute over statutory wording, a well-established legal principle requires courts to defer to a government agency's reasonable interpretation of the language at issue. In fact, the plaintiffs concede that their strained reading of the law could render several other provisions nonsensical.
The Supreme Court itself has said repeatedly that when construing laws, ''we must not be guided by a single sentence or member of a sentence, but look to the provisions of the whole law, and to its object and policy.''
The Affordable Care Act's challengers have taken the opposite approach and spent years scouring each sentence of the law for any and all possible lines of attack. Their persistence is impressive, but it does not make them right.
URL: http://www.nytimes.com/2014/11/08/opinion/health-care-reform-imperiled.html
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March 21, 2017 Tuesday
Late Edition - Final
On Health Law, G.O.P. Faces a Formidable Policy Foe: House Republicans
BYLINE: By EMMARIE HUETTEMAN
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 1312 words
WASHINGTON -- Halfway through Congress's 2013 summer recess, a letter landed on the desks of House Republican leaders demanding a new strategy to fight ''one of the largest grievances in our time.'' Give Congress the option to defund the Affordable Care Act, it said, or risk shutting down the government.
Republican leaders condemned the idea, and the 80 House Republicans who signed the letter acquired a nickname, courtesy of the conservative commentator Charles Krauthammer -- the ''suicide caucus.'' But it wasn't long before a bitter disagreement over the health care law snarled budget negotiations and resulted in a disruptive government shutdown that lasted 16 days. Republicans took the blame.
Three and a half years later, the letter's recipients -- John A. Boehner, then the House speaker, and Representative Eric Cantor of Virginia, the majority leader at the time -- are gone, casualties of the take-no-prisoners conservatism it espoused.
Representative Mark Meadows of North Carolina -- just a freshman Republican when he wrote that letter -- and several of the signers are now part of the hard-line group known as the House Freedom Caucus. True to their ''suicide caucus'' roots, they pose what is possibly the greatest threat to Republicans' long-awaited opportunity to scrap former President Barack Obama's biggest domestic policy achievement.
Panning the Republican plan as ''Obamacare Lite,'' the Freedom Caucus is gambling that its demands will not kill the repeal effort that has been a cause célèbre for all Republicans. And with President Trump's budget request previewing a bruising round of negotiations just weeks from now, its members appear to be on a collision course with their party's leadership at both ends of Pennsylvania Avenue.
Facing the prospect that their brand of combative conservatism could prove less appealing to voters than Mr. Trump's, the group has even expressed a tentative willingness to negotiate on a spending bill that may not immediately reduce the deficit, once a deal-breaking prospect during the Obama administration.
''We are willing to play ball, I think. We're willing to be open,'' said Representative Scott Perry of Pennsylvania, a member of the caucus. ''But we've got to know it's a consideration for you because it's a concern for us.''
Formed in early 2015, the Freedom Caucus threw itself into efforts that year to shut down the Department of Homeland Security over Mr. Obama's executive orders on immigration, and then the federal government over funding for Planned Parenthood. Increasingly angry at Mr. Boehner's efforts to quell his restive right wing, they pushed to toss him out. That October, he resigned.
So secretive that it will not disclose the names of its members, but headed by the persistently visible and often affable Mr. Meadows, the roughly three dozen members of the group have positioned themselves as the House's guardians of conservatism.
But some of their fellow Republicans chafe at what they see as their counterproductive propensity to engage in intraparty slugfests. Representative Devin Nunes -- the California Republican who in exasperation once called the instigators of the 2013 shutdown ''lemmings with suicide vests'' -- said the refusal to unite sends Republican leaders in search of Democratic votes, ''moving the agenda to the left.''
''At the end of the day, this is a team sport,'' he said. ''On the House side, you have to find a way to pass bills with your majority. No matter what, at all costs, you have to do that.''
House Republicans are keenly aware of the stakes for repealing the Affordable Care Act. About two-thirds of their 237 members were elected in the Tea Party wave of 2010 or later. Most campaigned on getting rid of the health care law.
''This is our generation's rendezvous with destiny,'' said Representative Jeff Duncan of South Carolina, another Freedom Caucus member.
''It's also a heavy lift,'' he added.
Though relatively few House Republicans belong to the Freedom Caucus, the fact that Republican leaders have little margin for error has only emboldened the group. Bills currently need at least 216 votes to clear the House, meaning Republicans can afford to lose just 21 members without Democratic help. (There are five vacancies in the House, four left by Republicans who took cabinet positions in the Trump administration.)
Members of the Freedom Caucus have expressed an assortment of concerns with the health care bill crafted by Speaker Paul D. Ryan and the Trump administration, which they argue does not go far enough toward repealing all aspects of the Affordable Care Act. Among other issues, they have dismissed its subsidies as a new entitlement program, and have argued that the measure should eliminate all essential health benefits requirements placed on insurers to control premiums. They endorsed one member's plan last month.
They are hardly the only Republicans with concerns about the measure. Representative Ileana Ros-Lehtinen of Florida and a few others in liberal-leaning districts are among other House Republicans who oppose it, as do key Republican governors; many outside groups, including the American Medical Association; and a handful of senators whose concerns clash with conservative opposition in the House.
But the caucus has become the stubborn obstacle to House passage, especially after top members of the Republican Study Committee -- a larger conservative group to which some Freedom Caucus members also belong -- emerged from a meeting with Mr. Trump Friday morning to say most of them would support the measure. Representative Jim Jordan of Ohio, a founding member of both groups, said he remained opposed.
A planned White House meeting for the Freedom Caucus, featuring pizza and bowling, was postponed last week because of snow.
The fact that ''over the past two weeks, the health care bill has gone from take-it-or-leave-it to we're-open-for-negotiation is proof that the Freedom Caucus is being effective,'' said Representative Andy Harris of Maryland, a member of the group.
For a year and a half, Speaker Ryan has navigated the tricky reality that members of his own party present the greatest obstacle to even shared policy goals like repealing the Affordable Care Act -- and an existential threat to his speakership.
In October, after Mr. Ryan distanced himself from Mr. Trump when a recording surfaced in which he was heard boasting of sexually assaulting women, members of the Freedom Caucus considered opposing his re-election as the party's leader. He was later re-elected with almost unanimous Republican support, including from the Freedom Caucus.
Representative Morgan Griffith of Virginia, another member of the Freedom Caucus, shrugged off the idea that the bill's failure would be an embarrassment for Mr. Ryan.
''People around here get all worked up on, oh my gosh, this is the end of the world,'' he said. ''Look, the speakership is defined by numerous votes over numerous years. And while you never want to lose when you're in leadership or speaker, sometimes you're going to lose. Welcome to legislating.''
Seeing a fellow disrupter in Mr. Trump, members of the Freedom Caucus have embraced him, but it is a risky and tenuous alliance. The group has viewed the willingness to cut entitlements as a practical test of conservatism; Mr. Trump vowed not to touch Social Security or Medicare during his campaign.
Praising Mr. Trump's proposed increases in military spending, Mr. Harris emphasized that the budget request would not add to the deficit thanks to strikingly deep cuts to social programs and other discretionary funding.
It also would not reduce the deficit. And Mr. Harris, like many Republicans, is concerned that Mr. Trump might make good on his promise for a $1 trillion infrastructure bill.
''You're never in total agreement,'' he said.
URL: http://www.nytimes.com/2017/03/20/us/politics/on-health-law-gop-faces-a-formidable-policy-foe-house-republicans.html
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October 21, 2014 Tuesday
Back to Blunt: Christie 'Tired of Hearing About' Minimum Wage
BYLINE: NICK CORASANITI
SECTION: US; politics
LENGTH: 320 words
HIGHLIGHT: Gov. Chris Christie of New Jersey reverted to his blunt style in a speech in Washington on Tuesday, offering a fiercer and more partisan perspective than he has on behalf of Republican candidates.
Gov. Chris Christie of New Jersey, taking a short break from his national tour to help elect Republican governors, reverted to his blunt style in a speech in Washington on Tuesday, offering a fiercer and more partisan perspective than he has on behalf of others.
On the Affordable Care Act, Mr. Christie said: "It doesn't work. It's a fiction. It doesn't work, and it should be repealed." He added that it was up to Republicans to offer an alternative.
Mr. Christie, who heads the Republican Governors Association, also said he was "tired of hearing about the minimum wage," saying, "I don't think there is a mother or father sitting around a kitchen table tonight in America who are saying, 'You know, honey, if my son or daughter could just make a higher minimum wage, all our dreams would be realized.' "
The governor also took a shot at teachers' unions, which he has battled frequently in his home state. "We are saps for the teachers' union," he said. "It's time to start offending them."
The speech was delivered during a lunch of steak, potatoes and sea bass at an all-day event at the U.S. Chamber of Commerce. Mr. Christie was careful to aim his jokes at himself, including one about how he's able to get things done. "Sometimes it's by my charm and good looks," he said. "Sometimes it's by taking someone out and giving them a beating."
Of course, the topic of Mr. Christie's potential candidacy for president in 2016 came up. Thomas J. Donohue, the chamber's president, introduced the governor by rattling off the similarities between himself and Mr. Christie, like their Irish and legal backgrounds.
One key difference, Mr. Donohue noted, was that he himself had made up his mind that he was "definitely not running for the president of the United States."
Mr. Christie then took the podium.
"Well, that's the announcement of the afternoon," he said. "Donohue's out. One down, a few more to go."
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(Economix)
November 22, 2013 Friday
A Conservative Alternative to Obamacare
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1381 words
HIGHLIGHT: Some conservatives propose to abolish both employer-based health coverage and Medicaid, relying on a private market with subsidies, a plan that seems politically and structurally unrealistic, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
"Escape From Obamacare" was the headline on The Wall Street Journal's lead editorial on Nov. 14.
Anticipating, or hoping, that the Affordable Care Act will collapse under the weight of its own architecture and the lack of managerial competence with which it is being put in place, The Journal exhorts Republicans to "revitalize and improve the old individual insurance market" as an alternative to the new system.
For decades that "old individual insurance market" was widely viewed as dysfunctional - the source of countless pitiable vignettes in the news media of sky-high premiums quoted to sick applicants, skimpy coverage, denials of coverage and rescissions of policies after insured people fell ill. It is precisely these problems that Title 1 of the new law has sought to address.
So it is fair to ask precisely what improvements in that dysfunctional market The Journal has in mind. As is well known, in health reform the angels and the devils live in the details.
Within the limits of an editorial, The Wall Street Journal could, of course, only hint at what such improvements might be. A somewhat fuller specification was offered in an accompanying op-ed piece, "A Conservative Alternative to Obamacare" by Ramesh Ponnuru and Yuval Levin.
These authors also leave many details of their plan unsaid. But I see in it a close cousin of a much more fully developed plan, published by eight distinguished health economists as a monograph commissioned by the American Enterprise Institute.
Details of that plan are available in the monograph, "Best of Both Worlds: Uniting Universal Coverage and Personal Choice in Health Care," and in a video of a news briefing on the plan, including critical comments by Nina Owcharenko of the Heritage Foundation and Henry Aaron of the Brookings Institution.
Basically, the authors want to get away from redistributing income from the relatively healthy (regardless of their income) to the relatively sick (regardless of their income) through health insurance premiums, as is the case under the community-rated premiums called for under the Affordable Care Act.
The authors propose instead a plan under which health insurers would be free to base their premiums on the individual applicant's health status, gender, age and family history, as has been the practice in the old individual market.
Redistribution of income would then take place outside of the pricing of health insurance.
It is impossible to do justice to the plan within the confines of this post, which is why I urge readers to pore over it carefully themselves. But in a nutshell, as I understand it, the plan calls for the following:
1. The current tax preference now accorded employment-based health insurance, under which employer-paid health insurance premiums are a tax-deductible business expense but do not count as taxable compensation of employees, would be abolished and, with it, probably much employment-based coverage.
2. Congress would annually specify a basic package of benefits (the "basic plan") to be offered by all private health insurers choosing to offer that basic plan and any other, more generous policies they may wish to offer on a new, private national health insurance exchange. The contents of the basic plan could fluctuate over time as Congress addresses the nation's fiscal situation.
3. All insurers participating in the exchange would have to quote each individual applying for coverage a premium for that basic plan, with the premium based on that applicant's own medical history and that of the applicant's family.
4. The federal government would provide the individual applicant support toward the premium for the basic plan if that premium exceeded a certain percentage of the applicant's adjusted gross income.
5. These federal premium support payments would be determined for each individual applicant on the basis of the lowest or second-lowest premium that individual was quoted for the basic plan.
6. Individuals would be free to purchase more generous coverage than the basic plan, at premiums also based on their own and their families' medical histories.
7. The federal-state Medicaid program would be abolished. Medicaid beneficiaries would be channeled to the new, private national exchange on which they would receive, at no cost to them, coverage for the basic benefit package. That coverage probably would be much leaner than Medicaid's current fairly comprehensive benefit package.
8. All Americans would pay a small safety-net tax to cover emergency care for individuals who are uninsured at the time of their emergency.
9. Funds now spent on Medicaid ($332 billion in 2011) and tax revenue gained by abolishing the current tax preference for employment-based insurance (about $300 billion a year) would be used to finance the federal premium-support payments.
The authors emphasize that theirs is only a broad sketch of the concept, leaving much flexibility for specifics.
To illustrate their concept, the authors develop a version under which the deductible for the basic plan rises with household income and according to whether the household is "extremely burdened" with health spending. An "extremely burdened" household would be one with income below 600 percent of the federal poverty level and whose medical expenditures in a year are greater than spending by 80 percent of all households in America. Table 3 of the monograph shows these deductibles and other co-payments.
To illustrate, for a family of four with an income of 150 percent of the federal poverty level ($33,525) and "not extremely burdened," the deductible would be 15 percent of household income ($5,029). The family would also face a 10 percent coinsurance rate on all medical bills. If that household were deemed "extremely burdened," the deductible would be zero, but the coinsurance rate would still be 10 percent.
By contrast, for a family of four with a household income of 700 percent of the federal poverty level ($156,450), the deductible would be 70 percent of income ($109,515) and the coinsurance rate 20 percent, whether or not the family were "extremely burdened" by medical bills.
At a household income of $223,500 and above, the deductible for this family would be equal to household income and the coinsurance rate would be 20 percent.
Families with high deductibles on the basic plan could, of course, purchase coverage with much lower deductibles, at premiums pegged to their health status and family medical history. Presumably, insurers could deny applicants such coverage, as they can now. Furthermore, it appears that insurers could also rescind policies in force if the applicant had submitted inaccurate health-status data as traditionally they have been able to do.
I salute the eight economists for sketching out for us a plan that seeks to combine premiums pegged on the health status of individuals with income redistribution outside of premium-setting.
The political appeal of such a complicated plan is for each reader to determine.
I also leave it to the reader to imagine the architecture of the new, private national health insurance exchange required by this scheme. It would be even more challenging than is Healthcare.gov under Obamacare.
Like Healthcare.gov, the new private insurance exchange would have to link to the Internal Revenue Service to verify income and to perform the complex calculations for premium support, if any.
That exchange would have to feature a plethora of premium quotes for the basic plan and for all more generous plans likely to be offered on the exchange, which might run into the hundreds.
Finally, to facilitate risk-based, individualized premium setting, that exchange would have to elicit from every applicant information in great detail on the applicant's medical history and that of his or her family. That intimate information would then be broadcast by the exchange to all private health insurers competing on the exchange.
Is this what a "new, improved old individual health insurance market" might look like?
The Slow Death of the Employer Mandate
In the Death Spiral We Trust
The Midterm Grade for HealthCare.gov
The Power of the Individual Mandate
Medicaid and the Incentive to Work
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December 4, 2016 Sunday 00:00 EST
Tom Price Is Eager to Lead H.H.S., and Reduce Its Clout
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 1322 words
HIGHLIGHT: Mr. Price, a congressman who was a practicing orthopedic surgeon for more than 20 years, has long sought to reduce the government's role in health care.
WASHINGTON - During his 12 years in Congress, Representative Tom Price has made clear what role he thinks the government should play in health care. It can be summed up in one word: less.
Throughout his career, Mr. Price - who has been picked by President-elect Donald J. Trump to be secretary of health and human services - has argued that the government should get out of the way of doctors and give patients more control over their health care.
This position is rooted in Mr. Price's experience as an orthopedic surgeon for more than 20 years. "As a physician," he said in the House in 2007, "I know oh so well how the intervention of the state and federal government into the practice of medicine destroys the ability to take care of people. It makes it so you can't provide quality health care for children and moms and dads."
Though he has worked for years to shrink the government's role, Mr. Price, a Georgia Republican, could soon lead a government agency whose expansive mission is to ensure care for more than 100 million Americans. As chairman of the House Budget Committee, he has tried to put a lid on federal spending. As secretary, he would be responsible for more than $1 trillion in spending, a number that will surge as the population ages.
The health secretary has immense discretion to impose, revoke and modify rules. A review of Mr. Price's record in Congress, including his speeches and legislative proposals, suggests that he would try to reduce the burden of federal regulations on health care providers, especially doctors.
As secretary, he would be responsible for the popular Children's Health Insurance Program, which insures eight million children at some point each year. In 2007, he opposed expansion of that program because, he said on the House floor, some children with private insurance would become eligible for "government-run socialized medicine."
Two years later, as the House debated a huge bill to jolt the economy out of a severe recession, Mr. Price jumped to his feet after spotting an item that provided $1.1 billion for research comparing the effectiveness of different drugs and medical treatments. He denounced it, saying he feared that the findings would be used to decide which items and services would be covered by insurance.
"This is indeed the foundation of rationing of American health care for each and every American," he said - a step toward Democrats' dream of "nationalized health care."
And in 2010, when Congress approved the Affordable Care Act, Mr. Price called it "a dark day for America," saying that "our founders are weeping" over a bill that was "an affront to federalism, an affront to individual liberty."
Senate Democrats are sure to challenge many of his positions at his confirmation hearings. Just as they distrust him on health care, he distrusts them.
"The true desire of those on the left," Mr. Price said on the House floor in 2007, "is to gradually and enticingly move all Americans to Washington-controlled bureaucratic health care." The bureaucracy, he said, is "not nimble like the private sector."
Mr. Price, whose father and paternal grandfather were also physicians, is a fierce advocate for doctors. But he says his primary concern is for patients. A desire to "empower consumers" has been a theme of his work in Washington.
In 2010, he said on the House floor that he had discovered that "there were more folks in Washington who affected what I could do for and with my patients than anybody I ever met in residency or in medical school." That, he said, "was wrong."
Mr. Price often reminds colleagues of a sentence in the original Medicare law, passed in 1965: "Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine."
"We violate this law all the time," Mr. Price said in 2005, referring to the government, especially "the bureaucrats, nonmedical individuals," who have written reams of rules defining the quality of care.
Mr. Price has opposed the Obama administration's effort to require employers and insurers to provide free coverage of birth control for women, saying it threatens religious freedom. The government should not "define and control what constitutes health care," he said in 2012, voicing a concern he has long expressed.
Women's rights advocates say Mr. Price's position on birth control is at odds with his antipathy to government interference in health care. Decisions about contraception, they say, should be left to women, in consultation with their doctors.
Soon after becoming a House member in 2005, Mr. Price introduced a resolution stating that Congress should move the nation toward a new model of health insurance, in which employers would give employees a certain amount of cash so they could buy insurance on their own, rather than enrolling in a health plan chosen by the employer.
"Moving from a defined-benefit system to a defined-contribution system," he said, would have a big advantage for consumers: They would "own and control" their insurance policies.
"That is a sea change," Mr. Price said. It means that "patients can vote with their feet" and go to a different insurer, regardless of whether the cost is paid by Medicare, Medicaid or an employer.
"Unleashing the power of choice and competition is the best way to lower health care costs and improve quality," he said.
House Republicans, led by Speaker Paul D. Ryan, embraced this idea in their "Better Way" policy agenda, issued in June. Under their proposal, Medicare would offer a fixed amount of money for coverage of each beneficiary. The money could be used to buy private insurance or to pay for the traditional Medicare program.
Democrats have assailed this approach, saying it leaves older Americans to fend for themselves if they need care that costs more than the federal contribution.
Many of Mr. Price's legislative proposals would affect the department he now hopes to lead. The stated purpose of one bill is "to restore to states the freedom and flexibility to regulate health insurance markets."
The bill would roll back insurance standards prescribed in the Affordable Care Act. Women could again be charged more than men of the same age for similar insurance policies, unless states banned such practices. Some people with pre-existing conditions who allow their insurance to lapse could have difficulty obtaining affordable coverage in the future.
Under another one of his bills, consumers could receive tax credits to help pay for insurance, but for many lower-income people, the amount of assistance would be less than what they receive under the Affordable Care Act.
Residents of one state might be able to buy insurance more easily from companies in other states. For consumers willing to take more responsibility for the cost of their medical care, it would be easier to set aside money in tax-favored health savings accounts.
But people with high-cost employer-sponsored health coverage could face new taxes. And patients who believe they have been injured by negligent doctors could find it more difficult to win damages in court.
If confirmed, Mr. Price will have a chance to practice what he has preached for decades. He could try to overhaul what he calls the "predatory trial lawyer litigation system." He could try to stop what he calls "regulatory oppression" by the federal government. And he could eliminate some of the mandates that he calls a "death knell for quality health care."
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PHOTO: Representative Tom Price, left, in 2015. Mr. Price was chosen to lead the Department of Health and Human Services. (PHOTOGRAPH BY DREW ANGERER FOR THE NEW YORK TIMES)
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(The New Old Age)
December 13, 2012 Thursday
New Life for the Class Act?
BYLINE: PAULA SPAN
SECTION: HEALTH
LENGTH: 192 words
HIGHLIGHT: Some advocates for the elderly hope that movement toward national long-term care insurance can be revived.
Now that President Obama has won a second term, the Supreme Court has ruled the Affordable Care Act constitutional and the election has made Congressional attempts to repeal it unlikely, a few advocates for the elderly are quietly talking about resurrecting the Class Act, or some variant of it.
The first voluntary national program for long-term care insurance, Class remains part of the health care law, even though the Obama administration shelved it last year. And certainly the need to protect families against the enormous financial burden of caring for older people or younger ones with disabilities will only grow more urgent.
"There's a window of opportunity now," said Connie Garner, director of the advocacy group Advance Class. "The stars are lined up to have a productive conversation."
Class, an acronym for Community Living Assistance Services and Supports, would have allowed working adults (including the self-employed) to pay reasonable monthly premiums for a fixed time, then be
Behind the Class Act, a Numbers Game
Good News and Bad on Long-Term Care
Administration Nixes the Class Act
More on the Class Act
The Class Act in the Crosshairs
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February 16, 2016 Tuesday
Bill Clinton Makes Case for Hillary Clinton's Candidacy in South Carolina
BYLINE: CHRIS DIXON
SECTION: US; politics
LENGTH: 646 words
HIGHLIGHT: Citing his wife’s achievements, Mr. Clinton suggested that a Hillary Clinton administration would continue the work of the Obama administration.
GREENVILLE, S.C. - Former President Bill Clinton stumped for his wife, Hillary, on Tuesday at community center packed with a diverse crowd of some 1,000 undecided voters, supporters and even a few conservatives.
Citing a litany of Ms. Clinton's achievements, and without naming her chief rival, Senator Bernie Sanders, Mr. Clinton suggested that a Hillary Clinton administration would continue the Obama administration's work to expand Medicaid and the Affordable Care Act, overhaul the student loan system and ensure background checks for all gun buyers.
Praising Mrs. Clinton as "a change agent," Mr. Clinton started the list with her first post-college job with the Children's Defense Fund in South Carolina, following with what he characterized as her dogged pursuit of early childhood and adult educational programs while he was governor of Arkansas. He singled out Home Instruction for Parents of Preschool Youngsters, a program Ms. Clinton first learned of in Israel and imported to Arkansas. Her efforts, he said, benefited Arkansas's poor from African-Americans in the Mississippi River Delta to the mostly white Ozark Mountains.
He also praised Clinton Foundation programs that provided two million clean-air cook stoves to families in poor countries and a generic drug program in Africa that he said increased the number of people receiving antimalarial drugs to 5.4 million from 1.7 million in the last several years. "You don't know those three and a half million people whose lives were saved," Mr. Clinton said. "But where they live, they know."
Some in the audience, like Daniel Cash, 51, a contractor, and Rena Jefferson, 40, who owns a home-cleaning business, remain undecided between Mrs. Clinton and Mr. Sanders. "I like some of the stuff Sanders is saying and some of what Clinton is saying," Mr. Cash said. "I just have to think and listen."
"That Clinton is going to continue the Affordable Care Act is my No. 1 thing," he added. "Bernie wants to make health care free for all citizens. But it's going to cost money. And where's that going to come from? Taxes. So I don't know if I want to do that. I want to know if it's possible that the wealthy really pay for the bulk of his plan. Because they can afford it."
Lacy Barrington, 44, a stay-at-home mom from Greenville and a former lawyer, pulled her three children, ages 7 to 11, out of school to see Mr. Clinton. "Hillary has a concrete record of change over decades," she said. "She will serve the country extremely well, she's well-respected around the world, unlike very many of the Republican candidates."
Ron and Jenny Babington, 36, who have four children and described themselves as "conservatively minded independents," walked a few blocks from their home to see the former president. Mr. Babington, a financial analyst, said his political leanings lined up more with Ron Paul than Mrs. Clinton or Bernie Sanders, but he and his wife said they were undecided in this race so far.
After Mr. Clinton's speech, Mr. Babington said he came away impressed. "If I was a liberal progressive, I would be sympathetic to her sort of pragmatic, can-get-things-done pitch," he said. "Honestly, I think Bernie's platform is too heavily dependent on this nebulous political revolution that is highly unlikely to materialize. The risks notwithstanding in terms of likeability, the F.B.I. investigation and all that just on the merits, I'd be inclined to support Hillary because she has the experience, and that pitch is compelling."
Still, the only person who would persuade the couple to vote for Ms. Clinton, they said, is Donald J. Trump.
"He scares me," Ms. Babington said.
"He has no guiding philosophies," Mr. Babington added. "He's only in it for himself."
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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June 27, 2014 Friday
Late Edition - Final
Most Will Be Able to Automatically Renew Coverage Under Health Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 732 words
WASHINGTON -- The Obama administration announced Thursday that most people would be able to renew subsidized health insurance coverage without filing an application and without going back to HealthCare.gov, the website that frustrated millions of consumers last fall.
But some people will have to go into the marketplace again -- if, for example, their income has changed or they want to shop for a better deal in 2015.
Under rules proposed Thursday by the administration, most people who purchased health plans in the federal insurance marketplace could automatically renew their coverage and premium subsidies provided under the Affordable Care Act.
More than 5.4 million people selected health plans in the federal exchange for 2014, and 86 percent of them were found eligible for subsidies that lower the cost.
If millions of people had to enroll again through HealthCare.gov it could have proved a logistical nightmare for many consumers, insurers and federal officials. ''There had been talk of everyone having to re-enroll, which would have been a disaster,'' said an insurance industry expert who meets often with federal officials and requested anonymity so as not to jeopardize those relationships.
Sylvia Mathews Burwell, the new secretary of Health and Human Services, said the administration was determined to minimize the hassles in the next open enrollment period, which runs from Nov. 15 to Feb. 15, 2015.
''We are working to streamline the process for consumers wishing to remain in their current plan,'' said Ms. Burwell, who issued the rules encouraging automatic renewal.
Aaron Albright, a spokesman at the Centers for Medicare and Medicaid Services, which runs the federal exchange, said: ''At least 95 percent of consumers in the marketplace will not have to do anything to renew their plans and their financial assistance. They won't have to do anything to re-enroll.''
Federal officials will specify the contents of notices that insurers will send consumers later this year. A typical notice says: ''Your health insurance coverage is coming up for renewal. You will be automatically re-enrolled and can keep your current coverage.''
The proposed rules show how the Affordable Care Act is becoming entwined in the fabric of national health policy and government regulation. Even as politicians continue fighting over the law, and many Republicans still hope to roll it back, but the Obama administration is writing rules to keep the program in operation for years.
Ronald F. Pollack, the executive director of Families USA, a liberal-leaning consumer group, said: ''The proposed rules are terrific. The overwhelming majority of people will be able to retain the coverage they gained this year and will be able to keep the subsidies that make insurance affordable.''
Joseph R. Antos, an economist at the conservative-leaning American Enterprise Institute, agreed that the proposed rules would simplify the administration of the program. But he said that they also increased the risk that ''many more people will have subsidies that are too high or too low next year.''
People may qualify for subsidies this year if they have incomes up to four times the poverty level (up to $45,960 for an individual). Consumers are supposed to update their information if they have a change in income or life circumstances, like marriage or the birth of a child.
If tax return information indicates that a person's income has increased to exceed five times the poverty level, the government will renew coverage in the same health plan but eliminate the subsidy.
Likewise, if a consumer has not authorized the insurance exchange to get updated tax information from the Internal Revenue Service, the subsidy payments will end on Dec. 31. The Congressional Budget Office estimates that subsidies this year will average $4,400 for each person who receives a subsidy.
While consumers do not have to do anything, it may be to their advantage to ask the government to reassess their eligibility and recalculate their subsidies. Premiums for most plans are expected to increase in 2015, and many consumers will be eligible for larger subsidies, federal officials said.
Supporters of the law had worried that they might have to help millions of people re-enroll in 2015. Without that requirement, Mr. Pollack said, ''much greater attention can be given to people who remain uninsured and have not been enrolled.''
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February 5, 2016 Friday
Late Edition - Final
Who Hates Obamacare?
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 27
LENGTH: 839 words
Ted Cruz had a teachable moment in Iowa, although he himself will learn nothing from it. A voter told Mr. Cruz the story of his brother-in-law, a barber who had never been able to afford health insurance. He finally got insurance thanks to Obamacare -- and discovered that it was too late. He had terminal cancer, and nothing could be done.
The voter asked how the candidate would replace the law that might have saved his brother-in-law if it had been in effect earlier. Needless to say, all he got was boilerplate about government regulations and the usual false claims that Obamacare has destroyed ''millions of jobs'' and caused premiums to ''skyrocket.''
For the record, job growth since the Affordable Care Act went fully into effect has been the best since the 1990s, and health costs have risen much more slowly than before.
So Mr. Cruz has a truth problem. But what else can we learn from this encounter? That the Affordable Care Act is already doing enormous good. It came too late to save one man's life, but it will surely save many others. Why, then, do we hear not just conservatives but also many progressives trashing President Obama's biggest policy achievement?
Part of the answer is that Bernie Sanders has chosen to make re-litigating reform, and trying for single-payer, a centerpiece of his presidential campaign. So some Sanders supporters have taken to attacking Obamacare as a failed system.
We saw something similar back in 2008, when some Obama supporters temporarily became bitter opponents of the individual mandate -- the requirement that everyone buy insurance -- which Hillary Clinton supported but Mr. Obama opposed. (Once in office, he in effect conceded that she had been right, and included the mandate in his initiative.)
But the truth is, Mr. Sanders is just amplifying left-wing critiques of health reform that were already out there. And some of these critiques have merit. Others don't.
Let's start with the good critiques, which involve coverage and cost.
The number of uninsured Americans has dropped sharply, especially in states that have tried to make the law work. But millions are still uncovered, and in some cases high deductibles make coverage less useful than it should be.
This isn't inherent in a non-single-payer system: Other countries with Obamacare-type systems, like the Netherlands and Switzerland, do have near-universal coverage even though they rely on private insurers. But Obamacare as currently constituted doesn't seem likely to get there, perhaps because it's somewhat underfunded.
Meanwhile, although cost control is looking better than even reform advocates expected, America's health care remains much more expensive than anyone else's.
So yes, there are real issues with Obamacare. The question is how to address those issues in a politically feasible way.
But a lot of what I hear from the left is not so much a complaint about how the reform falls short as outrage that private insurers get to play any role. The idea seems to be that any role for the profit motive taints the whole effort.
That is, however, a really bad critique. Yes, Obamacare did preserve private insurance -- mainly to avoid big, politically risky changes for Americans who already had good insurance, but also to buy support or at least quiescence from the insurance industry. But the fact that some insurers are making money from reform (and their profits are not, by the way, all that large) isn't a reason to oppose that reform. The point is to help the uninsured, not to punish or demonize insurance companies.
And speaking of demonization: One unpleasant, ugly side of this debate has been the tendency of some Sanders supporters, and sometimes the campaign itself, to suggest that anyone raising questions about the senator's proposals must be a corrupt tool of vested interests.
Recently Kenneth Thorpe, a respected health policy expert and a longtime supporter of reform, tried to put numbers on the Sanders plan, and concluded that it would cost substantially more than the campaign says. He may or may not be right, although most of the health wonks I know have reached similar conclusions.
But the campaign's policy director immediately attacked Mr. Thorpe's integrity: ''It's coming from a gentleman that worked for Blue Cross Blue Shield. It's exactly what you would expect somebody who worked for B.C.B.S. to come up with.'' Oh, boy.
And let's be clear: This kind of thing can do real harm. The truth is that whomever the Democrats nominate, the general election is mainly going to be a referendum on whether we preserve the real if incomplete progress we've made on health, financial reform and the environment. The last thing progressives should be doing is trash-talking that progress and impugning the motives of people who are fundamentally on their side.
Read Paul Krugman's blog, The Conscience of a Liberal, and follow him on Twitter.
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URL: http://www.nytimes.com/2016/02/05/opinion/who-hates-obamacare.html
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March 28, 2012 Wednesday
The Best Thing for the Democrats?
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 353 words
HIGHLIGHT: James Carville thinks a 5-4 ruling against the individual mandate would be great for the Democrats.
Now that the conventional wisdom on the health-care hearing has shifted-from a 6-3 or even 7-2 ruling in favor of the individual mandate's constitutionality to a 5-4 ruling against-the Democrats have to be thinking, if nothing else, about a public relations plan.
Cue James Carville, the veteran Democratic strategist, who told CNN's Wolf Blitzer yesterday that overturning the mandate "will be the best thing that ever happened to the Democratic party because health care costs are gonna escalate unbelievably."
He added: "You know what the Democrats are going to say - and it is completely justified: 'We tried, we did something, go see a 5-4 Supreme Court majority' the Republican Party will own the health care system for the foreseeable future."
That's spin-even though Mr. Carville said twice that it wasn't. It's a purely political and cynical way of understanding policy; if health care costs "escalate unbelievably" that's not good for anyone. (It's comparable to Republicans thinking a stalled economic recovery is good for their party because it's bad for the president's chances at re-election.)
It is true, however, that if the Supreme Court strikes down all or part of the Affordable Care Act, the burden of figuring out how fix the American health care system should by rights shift to the Republican Party.
Nearly 50 million people, or one in six Americans, do not have health insurance, and premiums for those who do are climbing ever higher. The classic liberal solution to that problem is single-payer, and that's certainly the most cost-effective way to make sure everyone has access to basic care. But during the legislative debates a couple of years ago it wasn't considered politically feasible, so the Democrats compromised with the individual mandate.
The Democrats, as Mr. Carville said, have tried. Do the Republicans plan to try, too, or do they expect Americans to accept the grossly inadequate status quo?
Opinion Report: Supreme Health
Opinion Report: The Anti-Injunction Act
Opinion Report: N.Y.P.D. Surveillance
Santorum's Super Tuesday Message: Romney Is a Liar
Opinion Report: The Blunt Amendment
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September 17, 2014 Wednesday
Late Edition - Final
Where Health Law Helps Voters but Saps Votes
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; REMAKING MEDICINE; Pg. 1
LENGTH: 1875 words
LOUISVILLE, Ky. -- The Affordable Care Act allowed Robin Evans, an eBay warehouse packer earning $9 an hour, to sign up for Medicaid this year. She is being treated for high blood pressure and Graves' disease, an autoimmune disorder, after years of going uninsured and rarely seeing doctors.
''I'm tickled to death with it,'' Ms. Evans, 49, said of her new coverage as she walked around the Kentucky State Fair recently with her daughter, who also qualified for Medicaid under the law. ''It's helped me out a bunch.''
But Ms. Evans scowled at the mention of President Obama -- ''Nobody don't care for nobody no more, and I think he's got a lot to do with that,'' she explained -- and said she would vote this fall for Senator Mitch McConnell, the Kentucky Republican and minority leader, who is fond of saying the health care law should be ''pulled out root and branch.''
Ms. Evans said she did not want the law repealed but had too many overall reservations about Democrats to switch her vote. ''Born and raised Republican,'' she said of herself. ''I ain't planning on changing now.''
Kentucky is arguably one of the health law's biggest early successes, with about 10 percent of the population getting coverage through the state's online insurance marketplace -- albeit mostly through Medicaid, not private plans -- and none of the technology failures that plagued other enrollment websites. The uninsured rate here has fallen to 11.9 percent from 20.4 percent, according to a recent Gallup poll that found only Arkansas had experienced a steeper decline.
But there is little evidence that the expansion of health coverage will help Kentucky Democrats in this fall's midterm elections. Republicans hold all of the state's congressional seats except for one, in a district centered in Louisville, and none are considered vulnerable this year. Republicans, who already control the State Senate, have a chance of taking the State House of Representatives, where Democrats hold an eight-seat majority. And several recent polls have put Mr. McConnell ahead of his Democratic opponent, Alison Lundergan Grimes, even though his approval ratings are tepid.
Mr. McConnell and other Republicans here, while more focused on other issues, like protecting Kentucky's coal industry, continue to attack the health law as a symbol of government overreach and Democratic bungling. And far from flaunting Kentucky's strong enrollment numbers, Democratic candidates -- most notably Ms. Grimes -- have remained reticent about the law, even its successes.
In many ways, the role that the law is playing in Kentucky politics reflects what is going on nationally as the midterm elections approach. The law remains deeply unpopular among Republicans and independents, and Republican candidates still use it to flog their Democratic opponents, although not as single-mindedly as before. That is partly because voters are more focused on other issues: A recent George Washington University Battleground Poll found that among likely voters who think the country is on the wrong track, only 5 percent blamed ''issues with Obamacare.'' More pointed to concerns about the economy, foreign policy, President Obama and Congress.
Why would people like Ms. Evans who are benefiting from the law vote for candidates who would dismantle it? Gov. Steven L. Beshear, one of the few Democrats forcefully promoting the law here, said many were driven by a dislike of Mr. Obama. A recent CNN poll found that only 33 percent of likely voters here approved of his job performance, and that 63 percent disapproved.
''The campaign by the Affordable Care Act's critics against it has been very effective in demonizing the phrase Obamacare and anything to do with the president,'' said Mr. Beshear, who cannot seek re-election next year because of term limits. ''So I think you find a reluctance on the part of people, even though the law is benefiting them, to publicly acknowledge it.''
Interest groups and candidates, including Mr. McConnell, have run more than 10,000 broadcast television spots here since January 2013 that mention the law in a negative way, according to Kantar Media's Campaign Media Analysis Group. Kantar found only one positive television ad, from Elisabeth Jensen, the Democrat challenging Representative Andy Barr in the state's Sixth Congressional District. The ad referred to Mr. Barr's votes to repeal the law, warning that he ''would restrict our access to affordable health care.'' Ms. Jensen, who is running in a swing district, also ran a radio ad praising the law last spring.
At the state fair's annual ham breakfast, Mr. Beshear tried to humanize the law, describing how several farmers in attendance had signed up for the new coverage and how one had used it to check out a spot that turned out to be skin cancer.
''It's not about the president,'' he told the crowd of 1,600, who did not applaud once during the six minutes he spent discussing the law. ''It's about you. It's about your families. It's about your children.''
That message has not persuaded people like Billy Bishop of Lexington, who is retired and gets health insurance through his former employer. He said his out-of-pocket costs had risen sharply while his coverage had gotten worse. He blamed the Affordable Care Act -- particularly its expansion of Medicaid to many more low-income Americans.
''I haven't heard anything good about it, to be honest,'' said Mr. Bishop, who has diabetes and heart stents. ''I've heard with this, you can't get doctors' appointments and people get put on wait lists for surgery.''
Nonetheless, at the state fair, Mr. Bishop, 57, and his wife, Cindy, 56, stopped by an information booth run by Kynect, the state's health insurance marketplace. Mrs. Bishop was curious about whether she could get less expensive coverage through Kynect, even though her husband refused to consider it for himself.
She took some brochures but said that regardless of what she learned about the cost, she and her husband would vote for Mr. McConnell. Mrs. Bishop said Ms. Grimes was ''with Obama on everything,'' and she called the president ''the worst we've ever had.''
At the teeming fairgrounds in late August, the Kynect booth handed out 26,000 reusable shopping bags stamped with its logo and toll-free number, and more fairgoers were clutching them than corn dogs or cotton candy. Crowds also gathered around information booths sponsored by the managed-care companies providing Medicaid coverage for the newly insured, one of which had a star University of Louisville basketball player greeting passers-by one day.
All the marketing did not sway Teri Eisenmenger of Louisville, who said she was against the health care law even though it had allowed her adult daughter to get Medicaid coverage.
''I don't like that people are being forced to buy insurance,'' Ms. Eisenmenger, 58, said, referring to the law's requirement that most Americans get health coverage starting this year or face a tax penalty. She is insured through her husband's job at a car dealership, but the premiums are high, she said -- $1,000 a month for the two of them -- and they might join a Christian health care sharing ministry instead. Members of these ministries pay monthly fees that help members with medical bills, and they are exempt from the penalty for not having insurance.
''Most people are going to see things through their partisan default position,'' said Representative John Yarmuth, Kentucky's lone Democrat in Congress. ''They separate the personal impact of policies from their perception of what is good for the country.''
Despite his unyielding attacks on the law, Mr. McConnell also takes positions that suggest he knows it would be difficult to dismantle. He has hedged on whether he would take away Medicaid from new enrollees and suggested, without explaining how, that the Kynect marketplace could survive even if the law were repealed.
Yet he frequently calls the law a ''job killer'' that is driving up premiums and deductibles for consumers -- charges that resonate with the many Kentuckians who are not directly benefiting from the law. He has spoken about the law at about 70 hospitals around the state since its passage in 2010, telling doctors, nurses and administrators that the law is ''a trillion-dollar hit on those of you who provide health care to the rest of us.''
At one such gathering last month, at Paul B. Hall Regional Medical Center in Paintsville, Dana Keaton Collett, the hospital's director of rehabilitation services, told Mr. McConnell that her insurance rates were rising so sharply that it was not worth keeping her coverage.
''This is the consequence of this awful law,'' Mr. McConnell replied, adding, ''I'm going to take you on the road with me.''
(Experts say that although insurance costs are indeed going up, they have been doing so for years, and a slowdown in the rate of health-cost growth since 2009 has moderated the increase in premiums for most people.)
Ms. Grimes typically avoids talking about the health care law but, when pressed, says she wants to improve it. At a candidate forum here last month, during which Mr. McConnell called the law catastrophic, Ms. Grimes said, ''We have to work to streamline the Affordable Care Act to make sure there aren't overburdensome regulations on our businesses.'' She also called for letting more people keep their old insurance policies, a point of contention that emerged last fall when several million people's plans were canceled because they did not comply with the law's coverage requirements.
Some party activists and political analysts say Ms. Grimes is missing an opportunity to excite the Democratic base -- and perhaps siphon votes from Mr. McConnell in places like southern and eastern Kentucky, where the drop in the uninsured rate has been especially steep -- by not vigorously defending the law. ''It may be her last, best chance,'' said Al Cross, a longtime Kentucky political reporter.
For now, Ms. Grimes is focusing on painting Mr. McConnell as a creature of Washington who will perpetuate partisan battles and gridlock.
''I think she realizes, as does the McConnell camp, that this is not going to be an issue that's going to sway people that much one way or the other,'' Mr. Beshear said. ''So she is concentrating her efforts on where they should be, reminding people of the last 30 years of Senator McConnell and the fact that he is part of the problem in Washington, and not part of the solution.''
Some Kentucky voters seem receptive to that message.
Karen Ekstrom, 60, who described herself as an independent voter, said she and her husband were deeply disappointed with the private insurance he got through Kynect. With the cost at $439 a month, ''I really feel we are being ripped off,'' she said.
Ms. Ekstrom, who works for a medical marketing company in Lexington, is ambivalent about Mr. Obama. But she said she planned to vote for Ms. Grimes, mostly because she sees Mr. McConnell as spending too much time trying to block Mr. Obama on the health care law and other initiatives.
''I'm tired of that,'' she said. ''It's a law. Let it go, move on and get some stuff done.''
Remaking Medicine: Articles in this series are examining how the Affordable Care Act is affecting lives in one American city.
URL: http://www.nytimes.com/2014/09/17/us/politics/kentucky-elections-obama-health-care-act.html
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GRAPHIC: PHOTOS: ROBIN EVANS, a supporter of the health care law who will vote nevertheless for a candidate who wants to repeal it
Jean Varble of Louisville picked up brochures for her grandchildren on the Affordable Care Act at the Kentucky State Fair.
Senator Mitch McConnell, Republican of Kentucky, left, is facing a challenge from Alison Lundergan Grimes, right, a Democrat. (PHOTOGRAPHS BY BRIAN POWERS FOR THE NEW YORK TIMES) (A18)
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March 2, 2017 Thursday
Late Edition - Final
Unity Is Elusive as G.O.P. Presses Health Overhaul
BYLINE: By THOMAS KAPLAN and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1173 words
WASHINGTON -- President Trump's address to Congress on Tuesday night buoyed House Republican leaders who were hopeful that his leadership would unite fractious lawmakers around a plan to replace the Affordable Care Act. But fundamental disagreements still divide Republicans on one of the central promises of their 2016 campaigns: repealing the health law.
While Mr. Trump appeared to back a health plan being drawn up by Republican leaders, it became clear Wednesday that lawmakers were continuing to argue over its details. Republican senators emerged from a closed-door meeting on health care tight-lipped.
Some have balked at a proposal to require workers to pay taxes on particularly generous employer-provided health benefits. Some are worried about the future of Medicaid.
But the central dividing line appears to be over how the federal government would help people purchase health insurance.
House Republican leaders would offer to help people buy insurance on the free market with a tax credit that, for some low-income households, could exceed the amount they owe in federal income taxes.
Some of the most conservative Republicans say the tax credit should not be more than the amount of taxes consumers owe. If the government makes payments to people with little or no tax liability, they say, that would amount to a new entitlement program, replacing one kind of government largess from President Barack Obama with another from Mr. Trump.
''Coming in as a Republican president with a new federal entitlement program?'' asked Representative Dave Brat, a conservative Republican from Virginia. ''That's your first big move? You would have politicians bidding up the cost, adding to the financial problems of other entitlement programs like Medicare and Social Security.''
After the president's speech, aides to the House speaker, Paul D. Ryan, crowed that they had the full backing of Mr. Trump for their health care plan.
But Mr. Trump was decidedly vague. He backed tax credits to buy insurance, but he did not clearly resolve the disagreement between Mr. Ryan and the most conservative Republicans.
''We should help Americans purchase their own coverage through the use of tax credits and expanded health savings accounts,'' Mr. Trump told a joint session of Congress.
The details of the tax credit could make a substantial difference to consumers. If a family is eligible for a $3,000 tax credit to buy insurance and owes $1,000 in federal income taxes, should it get only $1,000? Or should it get the full $3,000?
Most tax breaks reduce the amount owed to the government. A refundable tax credit can also result in payments from the government: If the credit exceeds a person's tax liability, the government pays him or her the excess.
''I think refundable tax credits are just another word for subsidies,'' said Senator Rand Paul, Republican of Kentucky.
Defenders of refundable tax credits say they are needed to make insurance affordable to people who pay little or no taxes.
''Otherwise, they're useless,'' said Representative Chris Collins of New York, one of Mr. Trump's top supporters in Congress. ''What good's a tax credit for folks who don't pay taxes?''
In fact, for those who cannot pitch in much of their own income, even a refundable tax credit is not likely to be enough to pay for a health insurance policy, Democrats say. That is one reason the Republican alternative is not likely to cover as many people as the Affordable Care Act.
At the meeting on Wednesday, several Republican senators expressed concern that the tax credit proposed by House leaders would be available even to people with high incomes who did not need federal assistance.
Earlier, Representative Kevin Brady, Republican of Texas and head of the Ways and Means Committee, said the credit would be a way to provide more equity in the tax code by creating a tax break for people who buy insurance on their own, similar to the break already available to people who get insurance through the workplace.
He predicted that Republicans would overcome their divisions.
''Rather than using his speech to divide Republicans,'' Mr. Brady said, ''it's really an opportunity for us to sit down and work through what remaining differences there are, and I'm confident we can.''
Mr. Brady and another architect of the House plan, Representative Greg Walden of Oregon, the chairman of the Energy and Commerce Committee, huddled with Republican senators on Wednesday. But lawmakers left the meeting with many unanswered questions and were not ready to endorse the House plan.
The fractures among Republicans have been on display in the past few days. On Monday night, three senators -- Mr. Paul, Mike Lee of Utah and Ted Cruz of Texas -- posted on Twitter in support of what they called #FullRepeal.
''If we fail to honor our commitment to repeal Obamacare, I believe the consequences would be, quite rightly, catastrophic,'' Mr. Cruz said on Wednesday.
The leaders of two groups of House conservatives, the Republican Study Committee and the House Freedom Caucus, also came out against a draft of the health care legislation that became public during last week's congressional recess. The groups have more than enough members to thwart House leaders' plan if they are determined to do so.
Senator James Lankford, Republican of Oklahoma, likened the leadership's tax-credit proposal to the earned-income tax credit, which supplements the wages of low-income workers. There has been ''a tremendous amount of improper payments'' in that program, he said.
Other Republican skeptics include Senators Thom Tillis of North Carolina and Lindsey Graham of South Carolina. ''There are other ways you can address that segment of the population,'' Mr. Tillis said of the working poor with little or no income tax liability.
Some Republicans are also concerned about the possibility of requiring workers to pay taxes on the value of employer-sponsored coverage exceeding certain thresholds. Employers and labor unions strenuously oppose such a move, which would affect people in the most expensive health plans and is similar in purpose to a provision of the existing law. Both measures are designed to curb overuse of health care and to help pay for the broader measures.
''I don't think it'd go over very good in the Senate,'' Senator Charles E. Grassley, Republican of Iowa, said last week.
Then there is the issue of Medicaid. Lawmakers from states that expanded Medicaid under the Affordable Care Act face pressure back home -- in some cases, from Republican governors -- to oppose sharp cuts to the generous federal funding that those states are receiving.
Senator Lisa Murkowski, Republican of Alaska, which has expanded eligibility for Medicaid under the health care law, said she wanted to be sure that her state could retain the expansion if its legislature wanted to do so.
''Alaska should have that option,'' she said.
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URL: http://www.nytimes.com/2017/03/01/us/politics/affordable-care-act-health-care-trump.html
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October 26, 2016 Wednesday 00:00 EST
Health Law Tax Penalty? I'll Take It, Millions Say
BYLINE: ROBERT PEAR
SECTION: US
LENGTH: 1062 words
HIGHLIGHT: A lot of healthy people are defying predictions by the Affordable Care Act architects and refusing to enroll, throwing off the math behind the system.
WASHINGTON - The architects of the Affordable Care Act thought they had a blunt instrument to force people - even young and healthy ones - to buy insurance through the law's online marketplaces: a tax penalty for those who remain uninsured.
It has not worked all that well, and that is at least partly to blame for soaring premiums next year on some of the health law's insurance exchanges.
The full weight of the penalty will not be felt until April, when those who have avoided buying insurance will face penalties of around $700 a person or more. But even then that might not be enough: For the young and healthy who are badly needed to make the exchanges work, it is sometimes cheaper to pay the Internal Revenue Service than an insurance company charging large premiums, with huge deductibles.
"In my experience, the penalty has not been large enough to motivate people to sign up for insurance," said Christine Speidel, a tax lawyer at Vermont Legal Aid.
Some people do sign up, especially those with low incomes who receive the most generous subsidies, Ms. Speidel said. But others, she said, find that they cannot afford insurance, even with subsidies, so "they grudgingly take the penalty."
The I.R.S. says that 8.1 million returns included penalty payments for people who went without insurance in 2014, the first year in which most people were required to have coverage. A preliminary report on the latest tax-filing season, tabulating data through April, said that 5.6 million returns included penalties averaging $442 a return for people uninsured in 2015.
With the health law's fourth open-enrollment season beginning Tuesday, consumers are anxiously weighing their options.
William H. Weber, 51, a business consultant in Atlanta, said he paid $1,400 a month this year for a Humana health plan that covered him and his wife and two children. Premiums will increase 60 percent next year, Mr. Weber said, and he does not see alternative policies that would be less expensive. So he said he was seriously considering dropping insurance and paying the penalty.
"We may roll the dice next year, go without insurance and hope we have no major medical emergencies," Mr. Weber said. "The penalty would be less than two months of premiums." (He said that he did not qualify for a subsidy because his income was too high, but that his son, a 20-year-old barista in New York City, had a great plan with a subsidy.)
Iris I. Burnell, the manager of a Jackson Hewitt Tax Service office on Capitol Hill, said she met this week with a client in his late 50s who has several part-time jobs and wants to buy insurance on the exchanges. But, she said, "he's finding that the costs are prohibitive on a monthly basis, so he has resigned himself to the fact that he will have to suffer the penalty."
When Congress was writing the Affordable Care Act in 2009 and 2010, lawmakers tried to balance carrots and sticks: subsidies to induce people to buy insurance and tax penalties "to ensure compliance," in the words of the Senate Finance Committee.
But the requirement for people to carry insurance is one of the most unpopular provisions of the health law, and the Obama administration has been cautious in enforcing it. The I.R.S. portrays the decision to go without insurance as a permissible option, not as a violation of federal law.
The law "requires you and each member of your family to have qualifying health care coverage (called minimum essential coverage), qualify for a coverage exemption, or make an individual shared responsibility payment when you file your federal income tax return," the tax agency says on its website.
Some consumers who buy insurance on the exchanges still feel vulnerable. Deductibles are so high, they say, that the insurance seems useless. So some think that whether they send hundreds of dollars to the I.R.S. or thousands to an insurance company, they are essentially paying something for nothing.
Obama administration officials say that perception is wrong. Even people with high deductibles have protection against catastrophic costs, they say, and many insurance plans cover common health care services before consumers meet their deductibles. In addition, even when consumers pay most or all of a hospital bill, they often get the benefit of discounts negotiated by their insurers.
The health law authorized certain exemptions from the coverage requirement, and the Obama administration has expanded that list through rules and policy directives. More than 12 million taxpayers claimed one or more coverage exemptions last year because, for instance, they were homeless, had received a shut-off notice from a utility company or were experiencing other hardships.
"The penalty for violating the individual mandate has not been very effective," said Joseph J. Thorndike, the director of the tax history project at Tax Analysts, a nonprofit publisher of tax information. "If it were effective, we would have higher enrollment, and the population buying policies in the insurance exchange would be healthier and younger."
Americans have decades of experience with tax deductions and other tax breaks aimed at encouraging various types of behavior, as well as "sin taxes" intended to discourage other kinds of behavior, Mr. Thorndike said. But, he said: "It is highly unusual for the federal government to use tax penalties to encourage affirmative behavior. That's a hard sell."
The maximum penalty has been increasing gradually since 2014. Federal officials and insurance counselors who advise consumers have been speaking more explicitly about the penalties, so they could still prove effective.
Many health policy experts say the penalties would be more effective if they were tougher. That argument alarms consumer advocates.
"If you make the penalties tougher, you need to make financial assistance broader and deeper," said Michael Miller, the policy director of Community Catalyst, a consumer group seeking health care for all.
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The New York Times
September 30, 2014 Tuesday
Late Edition - Final
Screening Smokers for Lung Cancer
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 22
LENGTH: 677 words
To the Editor:
Re ''A Cancer Battle We Can Win,'' by Andrea McKee and Andrew Salner (Op-Ed, Sept. 22):
Certainly screening for lung cancer in select populations has proved its value and deserves to be covered by Medicare, but readers should understand the long and controversial history of this procedure.
When it was first proposed, the concern was that smokers might get the idea that it was safe to smoke and be screened regularly. Pressure from health advocates compelled the researchers to include smoking cessation counseling for the participants of early trials. Then it was revealed that some of the early work was sponsored by a tobacco company.
As for winning the battle, reducing the number of lung cancer deaths by 20 percent may be significant, but we already know how to reduce the number of lung cancer deaths by 90 percent -- regulate cigarettes out of existence. All the steps required have been mapped out by the Centers for Disease Control and Prevention and the 2014 Surgeon General's Report. We just need to persuade some politicians to act.
EDWARD ANSELM New York, Sept. 22, 2014
The writer is medical director of Health Republic Insurance of New Jersey and an assistant professor of medicine at the Icahn School of Medicine at Mount Sinai.
To the Editor:
I encourage smokers and former smokers to seek out more information about the benefits and risks of lung cancer screening, then make an informed choice about what is right for them.
Here are some additional facts and issues to consider (drawn partly from an excellent Veterans Affairs publication called ''Screening for Lung Cancer''):
â- The evidence for benefit is based on a single, carefully conducted trial. It is unclear if the benefits shown in this trial will be replicated in routine practice.
â- The benefit of screening is small but important. According to research, with screening, three fewer people out of 1,000 would die from lung cancer over six years compared with those electing not to be screened.
â- Potential harms: Of 1,000 people screened over three years, 365 would have a false alarm. The false alarms would lead to additional testing, and a few people would experience serious complications from this testing.
â- Only 25 percent of participants in the trial were older than 65, and none were older than 74. False positive rates and the complications from biopsies of lung nodules are higher in older adults. The potential benefit from lung cancer screening in older adults may be substantially less than observed in the trial.
While it is laudable that some hospitals provide CT screening free to all qualified high-risk individuals, patients will need good insurance for further testing and treatment if they have a positive test. I am not arguing for or against screening, but rather that people should have the facts and discuss with their physician what is best for them.
JOHN WILLIAMS Chapel Hill, N.C., Sept. 22, 2014
The writer, an internist, is a professor of medicine at Duke University Medical Center.
To the Editor:
As a supporter of the Affordable Care Act, I find Andrea McKee and Andrew Salner's Op-Ed essay both hopeful and worrisome. They report significantly improved lung cancer survival rates for ''current and former heavy smokers'' who have a CT scan that costs several hundred dollars. They add that the ''screenings will be more affordable'' when the Affordable Care Act lists them as free preventive services in January 2015. They urge Medicare to follow suit.
But individual affordability means shared expense. The writers note the estimated nine million beneficiaries, but not the collective cost of perhaps $3 billion or more based on their figures. As the Affordable Care Act increases our shared responsibilities for one another's health care costs, perhaps we should limit ''free'' (that is, jointly paid) preventive services to cases involving a common health risk rather than a recognized personal risk.
DAVID CRAIG Indianapolis, Sept. 23, 2014
The writer is the author of ''Health Care as a Social Good: Religious Values and American Democracy.''
URL: http://www.nytimes.com/2014/09/30/opinion/screening-smokers-for-lung-cancer.html
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The New York Times
July 17, 2016 Sunday
Late Edition - Final
Obamacare's Kindest Critic
BYLINE: By THE EDITORIAL BOARD
SECTION: Section SR; Column 0; Editorial Desk; EDITORIAL; Pg. 12
LENGTH: 929 words
History will almost surely rank health care reform as one of President Obama's greatest accomplishments. About 20 million Americans have insurance that might otherwise have been unaffordable, and the law has cost much less than anticipated. But one senior administration official thinks the Affordable Care Act has fallen short. His name: Barack Obama.
Presidents usually wait until their memoirs to review their work. Not, in this case, Mr. Obama, who recently marked the act's sixth anniversary with an unusual article in The Journal of the American Medical Association. Health care costs are still much too high, he wrote, and 29 million people still lack coverage. He then sketched some ideas for the presumptive presidential nominees. Hillary Clinton is likely to listen, having proposed improvements of her own. Donald Trump, not so much. He has so far adopted the ''repeal and replace'' position of his party.
Six years ago, 16 percent of Americans did not have health insurance; that number is now down to 9.1 percent. People forced to pay out of their own pocket were often bankrupted. Some went without care, and others resorted to charity care at emergency rooms. The law has helped many of these people by expanding Medicaid, which insures the poor. For millions of others, it created health care exchanges where people could buy coverage with the help of government subsidies.
The act also required individuals to either buy insurance or pay a penalty (to help spread the costs), while mandating that businesses with more than 50 full-time workers provide insurance to their employees.
Also impressive is what the law has not done. Republicans who derisively labeled the program Obamacare said it would cost jobs and wreck the federal budget. Yet the economy has added more than 14 million jobs since Mr. Obama signed the measure, and, according to the Congressional Budget Office, the law has cost $157 billion, or one-quarter less than was forecast in 2010.
Still, too many people have been left out. For one thing, 19 states, including Florida, North Carolina and Texas, still have not expanded Medicaid, even though the federal government offered to pay the full cost for the first three years and 90 percent starting in 2020. If these states had opted in, four million more people would be eligible. But the Republicans who control the governments in these states are ideologically opposed to the health reform law.
And despite the subsidies, many people still can't afford health care. For some middle-class families who buy coverage on the exchanges, the cost of insurance and out-of-pocket expenses like co-pays and deductibles can add up to nearly a quarter of household income, according to the Urban Institute. It is no wonder then that nearly 80 percent of those who still do not have insurance say they cannot afford it.
Mr. Obama proposes several fixes. He recommends that the government offer its own health insurance, a so-called public option, on the exchanges in some parts of the country. That could help make health care more affordable in rural areas and smaller cities where only two or three insurers sell coverage. Republicans and some moderate Democrats fear that this could be the first step to a single-payer health care system. But there might be more support for a policy that is intended strictly for people in places with few choices.
Mrs. Clinton supports the public option and has even suggested that people between the ages of 55 and 64 be allowed to buy into Medicare, though she has not yet provided details of how that would work. Mr. Trump has said he wants universal health coverage, and has proposed tax deductions and allowing insurers to sell policies across state borders. Tax deductions would help some people but wouldn't be enough, experts say. And insurers can already expand into other states as long as they follow the laws and regulations of the states in which they want to do business.
In addition to the public option, lawmakers ought to consider bigger subsidies for insurance offered through the exchanges, an idea Mrs. Clinton supports. This can be done at a modest cost paid for by slightly higher taxes, according to several experts. In addition, both federal and state governments ought to do more to educate people about the subsidies available to help them buy insurance.
The system could also be made more efficient. The Affordable Care Act has pushed insurers, doctors and hospitals to focus on preventive care, as Mr. Obama notes in his article, and lawmakers can build on that progress. Congress, he added, should allow Medicare to negotiate drug prices with pharmaceutical companies, an idea that could help lower costs but faces stiff opposition from Republicans and even some Democrats.
Yet another way to reduce spending on drugs, experts say, is to set up a system under which government pays more for effective medicines than for comparable drugs with less impressive results. The Obama administration recently proposed experimentally testing these and other changes within Medicare. The pharmaceutical industry is resisting and has pressured legislators to do so, too.
What Mr. Obama has done here is unusual -- asking someone else to burnish a legacy of which he is personally proud. If the candidates (and Congress) pay attention, his request may also do a world of good for millions of Americans for whom decent health care remains out of reach.
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URL: http://www.nytimes.com/2016/07/17/opinion/obamacares-kindest-critic.html
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The New York Times
July 12, 2015 Sunday
Late Edition - Final
Expanding Health Care
SECTION: Section SR; Column 0; Editorial Desk; LETTERS; Pg. 10
LENGTH: 1127 words
Readers discuss the impact of Medicare and Medicaid at 50 and offer their suggestions.
To the Editor: In ''Medicare and Medicaid at 50'' (editorial, July 3), you referred to polls between 1999 and 2009 that showed ''consistent majorities in favor of expanding Medicare to people between the ages of 55 to 64 to cover more of the uninsured.'' The next day, ''Insurers Seek Steep Increases in Plans' Rates,'' a front-page news article, reported on likely double-digit rate increases -- something the Affordable Care Act can discourage but not prevent.
Isn't it time to accede to the wishes of the ''consistent majorities'' and begin dropping the qualifying age for Medicare one decade at a time? It would probably be less costly for consumers, since any increase in payroll taxes would be more than offset by lower premiums and out-of-pocket costs, it would provide truly universal care to those in the covered age groups and it would certainly be less inflationary.
MARCIA ANGELL
Cambridge, Mass.
The writer is a senior lecturer in social medicine at Harvard Medical School and a former editor in chief of The New England Journal of Medicine.
To the Editor: Congress created Medicare 50 years ago to provide seniors with health care, giving them protection against financial ruin and peace of mind. Five years ago Congress could have and should have extended Medicare to cover all Americans, creating a single-payer system with the much freer choice of doctors and hospitals that seniors enjoy. Instead, it passed the hopelessly complex Affordable Care Act, which has kept the wasteful and bureaucratic insurance industry in health care and left millions uninsured and millions more with woefully inadequate coverage. It has also cost far more than simply extending Medicare.
It is well known that people without insurance or with high deductibles wait longer to seek medical care; thus their illnesses or problems become more difficult to treat. And sometimes they die because they have no insurance (an estimated 50,000 every year). Those with Medicare have more protection against the devastating effects of illness and injury, get more help overcoming or living with disabilities, and are protected against financial ruin.
''Equal protection'' has been used, with some success, to improve access to education and, now, to allow same-sex couples to marry. It seems that an even stronger case can be made regarding access to health care -- which is considered a right in every other developed nation.
ANN TROY
San Rafael, Calif.
The writer is a pediatrician.
To the Editor: After 50 years, it is high time to finally correct a major structural flaw by moving coverage for long-term care from Medicaid to Medicare. If this were to happen, those of us in need of long-term care would no longer need to spend down most of our assets in order to qualify for coverage. Moreover, the services that would be covered would no longer depend on which state we happened to live in. It would also provide welcome relief to those states that have expanded Medicaid under the Affordable Care Act as they begin to assume their 10 percent share of the cost of the Medicaid expansion.
Most of all, it would provide enormous relief and peace of mind to the growing number of Americans who are struggling to find affordable long-term care for themselves or their parents. And for those who believe that this could never be done, bear in mind that seniors and their baby-boomer children represent two of the most powerful voting blocs in American politics.
PAUL JELLINEK
Mercerville, N.J.
To the Editor: The salient limitations of the Medicare and Medicaid programs that you correctly identify are unlikely to be overcome without reform of the physician payment system. By retaining fee-for-service payments, which private health insurers then emulate, young doctors have abandoned primary care and flocked instead to the more lucrative specialties. A step in the right direction: Continue the fee-for-service payment mechanism in primary care only, and pay specialists in some other way that reduces the perverse incentives to undertake procedures and operations when the scientific evidence fails to support them.
MATTHEW MENKEN
Princeton, N.J.
The writer is a neurologist.
To the Editor: Medicare provides better care at lower cost than private health insurance can achieve. But it is woefully underfunded and may become insolvent. Many argue for privatization. However, every health care system in the world, especially our private insurance industry, faces increasing costs and a decreasing willingness of patients (and taxpayers) to pay for them.
Remarkably, Medicare costs are rising slower than those of private insurance -- despite caring for older, sicker patients. Privately administered Medicare Advantage costs more than traditional Medicare; that's not because patients receive care they don't need, but because private insurance companies receive extra federal payments they don't earn. Clearly Medicare needs less private interference, not more.
Medicare delivers high value. Its critical features -- prepayment during high earning periods, reduced cost-sharing at time of need, inclusion of the broadest possible population, comprehensive benefits -- should be reinforced. Then these features should extend to the rest of us. Medicare for some is good. Medicare for all is better.
SAMUEL METZ
Portland, Ore.
The writer is an anesthesiologist and a member of Physicians for a National Health Program.
To the Editor: Your editorial rightly celebrates the impact that these two vital programs have had on the health and economic security of millions of Americans. With the enactment of the Affordable Care Act, our nation now has an even more mixed array of approaches to the financing of health care. This patchwork makes it nearly impossible to address health care systematically. One result is discontinuity of care, for which we all continue to pay a high price as patients and practitioners. Across our lives, health care coverage can change with age, income, employment, location and other variables.
Even without a unified health insurance mechanism, we need to find ways to facilitate continuity in health plan coverage and provider relationships for people, separate from the question of who is paying the bills. Ideally, our goal as a nation should be to enable individuals and their families to remain in the same health plan with the same team of providers throughout our lives.
WILLIAM J. ARNONE
Port Washington, N.Y.
The writer is chairman of the board of directors of the National Academy of Social Insurance.
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URL: http://www.nytimes.com/2015/07/12/opinion/sunday/medicare-and-medicaid-successes-and-drawbacks.html
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March 29, 2017 Wednesday
Late Edition - Final
Mindful of Midterm Elections, Republicans Are Divided on How to Proceed
BYLINE: By JONATHAN MARTIN
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 1182 words
WASHINGTON -- As they come to terms with their humiliating failure to undo the Affordable Care Act, Republicans eyeing next year's congressional campaign are grappling with a new dilemma: Do they risk depressing their conservative base by abandoning the repeal effort or anger a broader set of voters by reviving a deeply unpopular bill even closer to the midterm elections?
The question is particularly acute in the House, where the Republican majority could be at risk in 2018 if the party's voters are demoralized, and Democratic activists, energized by the chance to send a message to President Trump, stream to the polls.
Sifting through the wreckage of a disastrous week, Republican strategists and elected officials were divided over the best way forward. Some House Republicans pressed to move on to other issues and notch some victories that could delight their own loyalists while not turning off swing voters.
''We've got a lot of time to do real things on infrastructure, to do real things on tax reform, on red tape reform, and really get the American economy moving,'' said Representative Steve Stivers of Ohio, chairman of the National Republican Congressional Committee, the House campaign arm. ''We do those things and we still have a lot of time to recover.''
''If you're going to fumble the ball,'' he added, ''better to do so in the first quarter of a football game.''
Devising health care legislation that could appeal to both wings of the House Republican Conference -- the hard-line conservatives and more moderate members -- would require a nearly superhuman feat, added Representative Billy Long, Republican of Missouri.
''Not unless Harry Houdini wins a special election to help us,'' Mr. Long said about the prospects of cobbling together a coalition that could agree on how to repeal and replace the health care law.
But other longtime Republicans warned that if the party did not address what they have derided as Obamacare, an issue that has been central to their campaigns for the last seven years, they would incur a heavy political price in the midterm elections.
Midterm campaigns have increasingly become akin to parliamentary elections -- referendums on the party in power rather than on individual candidates, where turnout by dependable partisan voters is the deciding factor.
''If they fall on their sword on this, they're going to get slaughtered,'' said former Representative Thomas M. Davis III, a Virginia Republican who himself was once at the helm of the House campaign committee.
''Where parties get hurt in midterms is when their base collapses,'' Mr. Davis said. ''Democrats are going to show up regardless of what you do. If our voters don't see us fulfilling what we said we were going to do, they'll get dispirited.''
What troubles many Republican strategists is the specter of the party's most reliable voters being bombarded by reminders of their leaders' failure to address the health law. They fear a recurring story line sure to pop up every time insurance premiums increase, providers leave local networks, or, most worrisome, Republicans fund President Barack Obama's signature achievement.
Conservatives, many of whom opposed the House repeal bill, now warn that it is untenable to stand pat on the issue -- and that lawmakers will face retribution if they do not return to the repeal-and-replace effort.
''If people are looking at a situation where there's no action on this, there are going to be conversations about primaries,'' warned Michael A. Needham, the chief executive of Heritage Action for America, the Heritage Foundation's political arm, which worked to scuttle the Republican health bill last week.
That Republicans even find themselves in such a quandary just over two months after Mr. Trump was sworn in is at once extraordinary and not altogether surprising. Republicans who were then in office opposed the Affordable Care Act when it was enacted in 2010, yet they were paralyzed in efforts to undo it.
The paradox is predictable for a party that has been at war with itself since the final years of President George W. Bush's administration. Mr. Trump transcended those divisions last year in his campaign, but congressional Republicans remain riven between their hard-liners and mainstream conservatives.
Perhaps it was inevitable that these factions would clash over an issue as sensitive as remaking the American health care system. The purists -- often from politically safe districts -- believe the government should play almost no role in providing health insurance to its citizens. Placating them without endangering more pragmatic lawmakers worried about depriving constituents of their health coverage may be an impossible task.
''I think we need to start negotiating with Democrats instead of the Freedom Caucus,'' said a frustrated Mr. Stivers, referring to the most conservative bloc of House Republicans. ''They don't know how to get to yes.''
Democrats, though, have no appetite for conciliation: They see the Republican disarray over health care, and the broader tensions on display in the clash over the health care law, as a path back to the House majority.
Seizing on the Republicans' American Health Care Act, which according to a Quinnipiac University survey last week was supported by only 17 percent of Americans, Democrats have started digital advertising against the 14 potentially vulnerable House Republicans who supported the legislation in committee votes.
Some of these lawmakers represent districts that Hillary Clinton carried last year. They are as concerned about the consequences of casting a vote for the bill as they are about inviting a backlash from their bases for not addressing the issue at all.
Indeed, though much of the frustration from mainline Republicans has been directed at the Freedom Caucus, Republican lawmakers from pro-Clinton districts played just as big a role in torpedoing the American Health Care Act.
''I don't want to vote for a bill that has no chance of passing the Senate,'' explained Representative Leonard Lance of New Jersey, one such lawmaker who invoked the haunting tradition of House members' casting risky and, in some cases, career-ending votes, only to see their Senate colleagues sit on the proposals.
Mr. Lance, whose district Mrs. Clinton carried, and other Republicans insisted after the bill's collapse last week that they still wanted to wrestle with the Affordable Care Act in this Congress.
But former Representative Earl Pomeroy of North Dakota, a Democrat who lost his seat in 2010 in part because of his vote for the Affordable Care Act, said he thought Republicans like Mr. Lance were actually ''breathing a sigh of relief'' for averting a floor vote.
''It's a very, very tough vote for somebody in a competitive race,'' Mr. Pomeroy said. ''They may alienate their base by voting against it, but if they support a bill resulting in people losing their coverage, there will be electoral hell to pay.''
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URL: http://www.nytimes.com/2017/03/28/us/politics/2018-dilemma-for-republicans-which-way-now-on-obamacare.html
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GRAPHIC: PHOTOS: ''We've got a lot of time to do real things,'' said Representative Steve Stivers, above, referring to the Republican agenda. The question is, should repealing Obamacare still be on the list. (PHOTOGRAPHS BY J. SCOTT APPLEWHITE/ASSOCIATED PRESS
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June 25, 2012 Monday
How Wider Coverage Affects Health Spending
BYLINE: ANNIE LOWREY
SECTION: BUSINESS; economy
LENGTH: 595 words
HIGHLIGHT: Readers weigh in on an Oregon study that found a group of newly insured people were happier, but also incurred more medical expenses than uninsured people.
In an article over the weekend, I took a close look at a continuing health study relevant to the Supreme Court ruling due Thursday on the federal health care law, the Affordable Care Act.
The landmark study is the country's best analysis of how Medicaid coverage changes the lives of previously uninsured, low-income adults - about 17 million of whom would automatically qualify for coverage in 2014 under a provision of the law.
In 2008, Oregon had enough money to offer Medicaid to about 10,000 uninsured adults living at or below the poverty line. About 200,000 Oregonians fit that description, so the state held a lottery and about 100,000 individuals applied. A prestigious team of researchers then surveyed lottery winners and losers, giving a clear picture of the effect of coverage.
The Oregon Health Study found that getting Medicaid significantly improved study participants' self-reported mental and physical health, as well as their finances. But the Medicaid-insured group on average accounted for $778 more in annual medical expenses than the uninsured, a 25 percent difference.
Readers had a number of great comments and questions that I'll try to respond to here.
Several readers asked whether the increased medical expenses for the newly insured were a one-time bump or a permanent change, which would carry much more significant budget implications for the country.
Perhaps the newly insured got a lot of care as soon as they won Medicaid, because they could not afford it before. Perhaps they got more preventive care, holding down their medical expenses over a longer time frame. Perhaps if the researchers surveyed the participants two years or five years later, the uninsured and insured would be accounting for similar medical expenses.
The study authors address that important question, and conclude that the additional use of medical care is probably not due to pent-up demand. "All of the questions ask about current utilization or utilization over the last six months, not about utilization right after insurance began," the authors write. It seems that the insured just incur more medical expenses.
Other readers questioned whether we could trust the results given that the study is based on self-reported data. Maybe the participants who won insurance just thought they were healthier.
That's a great point - and it's one where the researchers are getting ready to give us a lot more evidence and analysis. The team has conducted more than 10,000 follow-up health examinations, testing participants' blood pressure and cholesterol, for instance. They are studying any measured differences between the insured and the uninsured, and will most likely have results ready sometime this year.
Finally, some readers questioned whether the findings of a single study of poor adults really have national relevance. I'd argue that they do, though with some caveats.
The study shows that winning coverage does have significant benefits for the uninsured and significant costs in terms of higher medical spending. But as the researchers write, its estimates are "difficult to extrapolate to the likely effects of much larger health insurance expansions, in which there may well be supply-side responses from the health care sector."
In other words, Medicaid might change when millions more people are using it. The broader health system might change, too. The Oregon study cannot speak to how.
Awaiting the Supreme Court's Health Care Ruling
Rationing Life-Years
The Unfunded Liabilities You Love
The Fork in the Road for Health Care
Define 'Welfare State,' Please
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April 27, 2013 Saturday
Late Edition - Final
The Next Step in Drug Treatment
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 20
LENGTH: 510 words
The mandatory-sentencing craze that drove up the prison population tenfold, pushing state corrections costs to bankrupting levels, was rooted in New York's infamous Rockefeller drug laws. These laws, which mandated lengthy sentences for nonviolent, first-time offenders, were approved 40 years ago next month. They did little to curtail drug use in New York or in other states that mimicked them, while they filled prisons to bursting with nonviolent addicts who would have been more effectively and more cheaply dealt with through treatment programs.
The country is beginning to realize that it cannot enforce or imprison its way out of the addiction problem. But to create broadly accessible and effective treatment strategies for the millions of people who need them, it must abandon the ''drug war'' approach to addiction that has dominated the national discourse in favor of a policy that treats addiction as a public health issue.
The Affordable Care Act sets the stage for such a transformation by barring insurers from denying coverage to people with pre-existing conditions, including substance dependency. The administration's new National Drug Control Strategy -- described in a lengthy document promoted by the White House this week -- calls for, among other things, community-based drug-prevention approaches that fully integrate treatment with the health care system. President Obama's budget, meanwhile, calls for a $1.4 billion increase in treatment funding.
To its great credit, New York was one of the first states to back away from the policies it helped to create. In 2009, it revised the Rockefeller laws, with the aim of sending more low-level, nonviolent offenders to treatment instead of to prison. That step leaves it in a good position to take advantage of the Affordable Care Act and create a system for treating drug problems that is free of the poor coordination and interagency conflicts. A timely new report issued by the New York Academy of Medicine and the Drug Policy Alliance, an advocacy group, provides a detailed blueprint for how the state could remake its drug treatment delivery system and remove public policy obstacles to timely and accessible treatment.
It notes, for example, that agencies often work at cross-purposes, in some cases penalizing, instead of helping, addicts. Addicts who avoid H.I.V.-AIDS exposure by getting clean needles at publicly funded centers are then arrested for having ''drug paraphernalia.'' Those with drug felonies on their records can be denied access to affordable public housing. Those who seek medical treatment for illnesses, and especially for pain, are often suspected of exaggerating their ailments to get drugs.
The report calls on the governor to convene a multiagency task force of the various state agencies and departments that encounter drug users, including social service agencies and the education and court systems. The ever more pressing purpose would be to improve the delivery of quality services to people who are too often banished to the margins of the health care system.
URL: http://www.nytimes.com/2013/04/27/opinion/the-next-step-in-drug-treatment.html
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October 4, 2013 Friday
Shutdown Din Obscures Health Exchange Flaws
BYLINE: Robert Pear
SECTION: US
LENGTH: 853 words
HIGHLIGHT: Members of both parties say the federal shutdown may give the Obama administration time to work out the kinks in the insurance exchanges under its health care law.
The shutdown of many federal operations and activities this week has obscured widespread problems in the opening of insurance exchanges under President Obama's health care law, giving the administration time to work out the kinks, members of both parties say.
In a stark contrast, the exchanges - online markets where consumers can shop for insurance - opened on Tuesday as much of the government was closing because of an impasse between Mr. Obama and Congressional Republicans over federal spending.
Millions of people were still frustrated Friday when they tried to #GetCovered, as instructed on Twitter by Mr. Obama, Lady Gaga and other celebrities.
Since the federal exchanges opened Tuesday, 8.6 million people have visited its Web site, and its telephone call center has received 406,000 calls, officials said Friday. They declined to say how many people had enrolled in health insurance plans. A section of the Web site where people apply for coverage will be taken down for several hours a day over the weekend so technicians can upgrade its capabilities, the administration said.
The law is at the center of the stalemate that has blocked funds for many federal programs.
Republicans want to repeal or delay it or make major changes, but Mr. Obama refuses to negotiate over the future of the law, which converts coverage from a privilege to a right, starting in January.
Lawmakers and lobbyists say the law's Republican opponents may have overplayed their hand this week, making it easier for supporters to brush aside criticism.
E. Neil Trautwein, a vice president of the National Retail Federation, said the standoff had "hardened the positions" of House Republicans, Senate Democrats and the White House, reducing the chances for changes that could make the law more workable for employers.
In general, the law requires larger employers to offer coverage to full-time employees, those who work, on average, at least 30 hours a week. Many employers are lobbying for legislation that would alter the definition and reduce the number of businesses subject to the employer mandate.
Senators Ted Cruz of Texas and Mike Lee of Utah, both Republicans, have led the campaign to strip money from the Affordable Care Act, although many Republican senators have expressed deep reservations about the tactic, saying it is unlikely to succeed.
"This was a self-inflicted wound," said one Republican on Capitol Hill, who spoke candidly on the condition of anonymity. "The push to defund the health care law was ludicrous from the beginning. It had no chance of success. But it became a cause célèbre for the hard right and obscured all the work we had done to investigate and highlight problems with the law."
On one point, many liberals and conservatives agree. It will be hard to take away government-subsidized coverage once people have it.
At a Tea Party gathering in Texas in August, Mr. Cruz said the president wanted to get people "hooked on the subsidies, addicted to the sugar."
"If we get to Jan. 1, this thing is here forever," Mr. Cruz said, according to The Texas Tribune.
Ronald F. Pollack, the executive director of Families USA, a liberal-leaning consumer group, said: "I agree with Senator Cruz. Once people experience the benefits and protections of the Affordable Care Act, it will be hard, if not impossible, to take them away."
The Obama administration had promoted its Web site for weeks as the best source of information on health insurance. But insurance agents, like consumers, were often stymied when they tried to use it.
"I am president of the National Association of Health Underwriters, and I could not get on the Web site," said Thomas M. Harte, a New Hampshire insurance broker who wanted to help clients. "I have tried more than a dozen times, in the middle of the day and the middle of the night."
Many users found they could not create the online accounts needed to see what health plans were available.
"The president calls these glitches, a nice poll-tested, fairly benign-sounding word," said Senator John Cornyn, Republican of Texas. "But these were systemic failures of the Obamacare exchanges - obviously, not ready for prime time."
Democrats, by contrast, were ecstatic. They said the problems were caused by the unexpectedly high number of visits to the Web site, which showed huge public demand for more affordable insurance.
A few persistent people said they had cleared the hurdles.
Emily R. Wright, 28, a student at East Tennessee State University, said she had signed up for a Blue Cross and Blue Shield policy in about a half-hour, after repeated efforts to get on the Web site. She said she had a painful gynecological condition, endometriosis, and qualified for a subsidy that would halve her premium, to $125 a month.
"I'm thrilled I can get treatment now," Ms. Wright said.
Readers Ask About Families Who Want Different Plans, and Rise in Costs
Problems at Health Care Web Site Not From Online Attack, Experts Say
Readers Ask About Subsidies and Other Health Care Law Provisions
Closer Look at Polls Finds Views of Health Law a Bit Less Negative
Federal Data Reveals Variety of Health Care Plans
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October 27, 2016 Thursday
Late Edition - Final
Rising Premiums for Obamacare
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 26
LENGTH: 614 words
To the Editor:
''Choices Fall in Health Law as Costs Rise'' (front page, Oct. 25) does not provide adequate context for its figures and intimations. Before the Affordable Care Act, health insurance costs were virtually out of reach already for many people, and rising every year. Obviously, this was a major reason a new system begged for creation.
Moreover, in addition to all the people who could never get insurance, there were many who lost their insurance eligibility if they had a pre-existing condition, whether self-employed or changing jobs. Egregious hardship cases abounded.
When states stop sabotaging the system by refusing to accept federal aid to expand Medicaid and when the public option is restored to the Affordable Care Act as intended, the differences will become more obvious between where we are and where we would have been, absent a leader who was willing and able to finally tackle the long-feared, monstrous challenge of building a lifesaving health care system.
BARRY FELDMAN
New York
To the Editor:
Articles such as this may leave the impression that the only health insurance premiums subject to significant increases are those offered under the Affordable Care Act. In fact, employer-based private insurance premiums are also on the rise.
As a 61-year-old with a chronic illness, I'm fortunate to be covered under my husband's plan. But come January, our premiums will increase 36 percent -- for the least expensive option. The current political climate has focused unbalanced attention on the flaws of Obamacare and distracts us from the more important problem: seeking solutions to the spiraling cost of health care for all Americans.
SUZY SZASZ
Richmond, Va.
The writer is the author of ''Lupus: Living With It.''
To the Editor:
So Obamacare premiums are going up. So there are some other problems with the program. Can anybody point to any other big government program that hasn't had some growing pains and hiccups in its early years?
What matters -- contrary to Republican claims of imminent doom -- is that millions of our fellow citizens now have health care coverage that they'd been unable to afford for years, and that their lives are immeasurably better as a result. That coverage will be preserved as we get on with the task of stabilizing prices and making necessary corrections to the overall program.
And that, of course, requires electing a Democratic president and getting more Democrats into Congress. As in everything else, the future well-being of us all depends on the outcome of this election.
KATHY HEGGEMEIER
Cary, N.C.
To the Editor:
Re ''Growing Costs of Health Law Pose a Late Test'' (front page, Oct. 26):
Donald Trump's promise to repeal and replace Obamacare will undoubtedly make the costs of health care even higher instead of lower.
If Obamacare is repealed, insurance companies will undoubtedly go back to denying policies for people with pre-existing conditions, and it's doubtful that Mr. Trump's proposal to allow the purchasing of health insurance policies across state lines will help.
However, forcing health care providers to stop price gouging is a viable solution to the continually rising costs of health care. In September, Hillary Clinton publicly put forth a plan that would hold pharmaceutical drug companies accountable for unjustified price increases by imposing new penalties.
On the other hand, Mr. Trump's proposal for reducing price gouging is allowing the government to negotiate prices with drug companies for Medicare recipients. Unfortunately, this will result in drug companies charging everyone else even higher prices to make up the difference.
KAY WEEKS
Pensacola, Fla.
URL: http://www.nytimes.com/2016/10/27/opinion/rising-premiums-for-obamacare.html
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The New York Times
November 10, 2016 Thursday
Late Edition - Final
Health Care; Gutting Aid
BYLINE: By ROBERT PEAR
SECTION: Section P; Column 0; Politics; Pg. 6
LENGTH: 552 words
WASHINGTON -- Mr. Trump has promised to repeal Mr. Obama's singular domestic achievement, the Affordable Care Act, and Republicans in Congress have shown the way. Republicans will not have the 60 votes in the Senate needed to pass most major legislation, but through a parliamentary procedure called budget ''reconciliation,'' they have already done a dry run to gut the existing law without facing a Democratic filibuster.
''Trump can start undoing the law administratively, but most of the action will lie with Congress,'' said Chris Jacobs, a conservative health policy analyst who used to work for Republicans on Capitol Hill.
Many provisions of the health law are now deeply embedded in the nation's health care system. Uprooting them would be a complex political and logistical challenge. Insurers now accept the idea that they cannot deny insurance, or charge higher prices, to people who have been ill.
And Congress may not move instantly to roll back the law without a clear idea of how to replace it -- how to insure the 20 million people who have gained coverage under the Affordable Care Act.
Moreover, the Trump administration will not be able to reverse unilaterally the expansion of Medicaid authorized by the health care law. Thirty-one states, including some with Republican governors, have expanded eligibility, with big infusions of federal money. Many of these states would balk at efforts to undo the expansion of Medicaid. The new Medicaid beneficiaries and health care providers, including hospitals, would also fight to preserve the expansion of Medicaid.
So the political environment could change immensely. Congress may spend months on hearings, debate and legislative maneuvering before making radical changes in the health law, on which public opinion has always been deeply divided. An army of lobbyists for doctors, hospitals, consumers, drug makers and insurance companies will descend on Capitol Hill to shape the legislation.
The requirement for most Americans to carry insurance -- the ''individual mandate,'' enforced through tax penalties -- is one of the most unpopular provisions of the law and is a prime target for Republicans eager to dismantle it. Republicans could also pass legislation to lift the requirement for larger employers to offer coverage to their workers, under the employer mandate.
It is not certain that Congress would repeal the health law in its entirety, but Mr. Trump and Republicans in Congress could definitely shift direction, reducing the role of government in health insurance markets, cutting back federal regulation and requirements so insurance would cost less and no-frills options could proliferate.
Mr. Trump would encourage the sale of insurance across state lines, in a bid to increase competition. He and the House speaker, Paul D. Ryan of Wisconsin, have said they will convert Medicaid, now an open-ended entitlement, into a block grant, giving each state a lump sum of federal money to provide health care to low-income people.
And Mr. Trump would encourage greater use of health savings accounts and let people take tax deductions for insurance premium payments.
-- ROBERT PEAR
_____
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What Does Trump's Executive Order Against Obamacare Actually Do?;
Public Health
BYLINE: MARGOT SANGER-KATZ
SECTION: UPSHOT
LENGTH: 1177 words
HIGHLIGHT: Major changes to health policy will require new legislation, not an executive order.
Donald J. Trump ran on a campaign promise to dismantle the Affordable Care Act. So it should not come as a surprise that he has signed an executive order urging his administration to fight it as much as possible.
But that order, alone, won't allow President Trump to unwind the sprawling health law known as Obamacare.
Mr. Trump and Republican leaders in Congress are engaged in negotiations about legislation that might substantially undo or replace the health law. Even before the inauguration, Congress took a first step toward gutting major provisions.
But as that process underscores, major changes to health policy will require new legislation. The Trump executive order should be seen more as a mission statement, and less as a monarchical edict that can instantly change the law.
Mr. Trump has sent a strong signal that he intends to fight the health law, but he sent signals that were strong on the campaign trail, too, just in less legalistic language. And the order, crucially, notes that agencies can act only "to the maximum extent permitted by law." (How the Trump administration interprets those permissions, of course, is yet untested.)
The order spells out the various ways that a Trump administration might fight the parts of the health law until new legislation comes: by writing new regulations and exercising discretion where allowed. Regulations can be changed, but, as the order notes, only through a legal process of "notice and comment" that can take months or years.
On matters of discretion, the administration can move faster, but there are limited places where current law gives the administration much power to quickly change course.
How much of the order is bluster and how much it signals a set of significant policy changes in the pipeline is unclear. The order was not specific and did not direct any particular actions.
"Right off the bat, what do they do - something incredibly cryptic that nobody understands," said Rodney Whitlock, a vice president of M.L. Strategies, a Washington consulting firm. Mr. Whitlock was a longtime health policy aide to Senator Chuck Grassley, a Republican from Iowa.
The easiest way for the Trump administration to undermine the health law would be to stop defending a lawsuit brought by the House of Representatives. That suit saidthat the Obama administration lacked the authority to pay certain Obamacare subsidies. A lower court ruled for the House, meaning that by simply withdrawing from the appeal, the Trump administration could start a process to eliminate those subsidies and cause a collapse of the insurance market. Mr. Trump's order said nothing about that policy choice.
Another important area of discretion has to do with exemptions to the law's unpopular individual mandate to obtain insurance. Under the law, all Americans who can afford it are expected to obtain health insurance, unless they have experienced some hardship that would make it impossible. People who feel there has been such a hardship can apply for an exemption, and employees in the Department of Health and Human Services and the Internal Revenue Service can decide on their case. Under a Trump administration, it might become easier to claim hardship and get out of the requirement to buy insurance.
But people seeking those exemptions will still have to apply for them, in writing, and can do so only at particular times of the year. Current law requires them to provide documentation supporting their claim that they have recently filed for bankruptcy, for example, or been evicted, and they must legally attest to their honesty. The Trump administration could create new categories of hardship, but that would take time. And rules that effectively eliminate the requirement would almost certainly result in litigation.
"It's not a hardship to have to comply with the law, almost by definition," said Timothy Jost, a professor of law at Washington and Lee University. Mr. Jost, who supports the health law, has examined the underlying regulations in detail.
Defanging the individual mandate could have significant consequences for the individual insurance markets. If fewer healthy people buy insurance, the costs of insuring everyone else will rise, leading insurance companies to raise prices or flee the market.
Last week, the Congressional Budget Office published its estimate of what would happen under a law that eliminated the mandate and some other provisions: 18 million people would lose their insurance next year alone. It's possible that insurers will look at the language of the order and get skittish, setting off a market collapse next year. But the order itself doesn't yet change any rules. The health and human services department and the I.R.S. will have to take further action.
"Is this mostly a symbolic gesture or a signal that they intend to take apart the law piece by piece to the extent they can?" said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health research group. "At a minimum, this creates a lot of uncertainty for insurers at a pretty critical time."
The order directs the administration to give states more autonomy in directing health policy. And there's a clear mechanism for that: Medicaid law provides a process in which states can waive many of the program's usual rules to attempt "demonstration projects."
Administrations have latitude under the law to decide what sort of new programs qualify. Mr. Trump's selection for the administrator of the Centers for Medicare and Medicaid Services, Seema Verma, has been an innovator in pushing this process in more conservative directions. Her selection, even more than the order, was a sign that the Trump administration would become more open to new Medicaid rules, including possible work requirements to obtain coverage, or premiums even for very poor Americans.
But, as with the exemptions, there is still a process for such policy changes. States must submit detailed applications for waivers for the rules, and there is a legal review process that typically takes months.
Mr. Trump recently promised that his team was developing a health care plan far better than the Affordable Care Act, that would insure more people and lower their costs. For people who heard that and thought Mr. Trump had gone soft on Obamacare, his executive order may come as a shock. But nothing in the order changes the law on its own. Whether Mr. Trump's intention is a smooth transition or a rapid disruption in current policy will be determined by what comes next.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
PHOTO: President Trump signing his first executive order on Friday, aimed at the Affordable Care Act. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)
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June 26, 2015 Friday
Late Edition - Final
Wisdom From the Supreme Court
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 26
LENGTH: 883 words
On Thursday morning, for the second time in three years, a majority of the Supreme Court rightly rejected a blatantly political effort to destroy the Affordable Care Act. The case challenging the law, King v. Burwell, was always an ideological farce dressed in a specious legal argument, and the court should never have taken review of it to begin with.
Its core claim -- that an ambiguous four-word phrase buried deep in the 900-page law eliminates health insurance for millions of lower-income Americans -- was preposterous. The entire point of the law, as embodied in the title of its first chapter, is ''Quality, affordable health care for all Americans.''
Writing for a six-member majority, Chief Justice John Roberts Jr. agreed that this clear, overriding purpose was the guiding principle. ''Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.''
In all the years leading up to the law's passage, no one questioned that purpose. Not a single person involved in passing or interpreting the law -- including members of Congress, health-care journalists, and Supreme Court justices themselves -- ever expressed a belief that subsidies would not be available on federally-operated exchanges. But the current challenge, brought to you by some of the same tireless conservative and libertarian activists who tried and failed to kill the health reform law in 2012, fabricated an alternate history out of thin air.
Their argument, based on an intentional misreading of four words, was that the tax-credit subsidies that make the law work are available only in the 13 states that fully run their own health care exchanges. Because a sub-sub-subsection of the law dealing with the calculation of those tax credits refers to an exchange ''established by the state,'' the challengers argued, no subsidies are available to the millions of Americans who live in the 34 states where the federal government runs the exchange.
It was a grandly orchestrated charade sold to people who were already furious about the law and just needed a legal rationale, however far-fetched, to try to gut it.
And it worked on the three justices whose disdain for the law has always been clear: Antonin Scalia, Samuel Alito Jr. and Clarence Thomas. In a dissent laced with outrage and mockery, Justice Scalia called the court's decision ''quite absurd,'' and quipped, ''We should start calling this law Scotus-care.'' But of course it was the justices' choice to hear challenges to the law in 2012 and this term, even though both were legally frivolous.
But as Chief Justice Roberts explained in detail, the health reform law depends on tax-credit subsidies to make health care affordable for more than six million Americans. Eliminating subsidies ''could well push a state's individual insurance market into a death spiral,'' he wrote, since fewer people would enroll and premiums for everyone would shoot up -- the very result Congress designed the reform law to avoid. To drive the point home, he quoted the dissenting justices' own words in the 2012 case, in which they openly admitted that without federal subsidies, ''the exchanges would not operate as Congress intended and may not operate at all.''
Thursday's decision was a powerful defense of the law, stronger than observers might have expected from this court. The justices could have upheld the provision on subsidies to federal as well as state-run exchanges as a reasonable exercise of discretion by a government agency -- in this case, the Internal Revenue Service, which issued the challenged regulation. But in that case, a future president could simply have ordered the I.R.S. to change the regulation. Instead, the court focused on the broader structure of the law itself, preserving the proper reading of it regardless of the politics of the next administration.
''In a democracy, the power to make the law rests with those chosen by the people. Our role is more confined --'to say what the law is,''' Chief Justice Roberts wrote, quoting the Supreme Court's foundational 1803 ruling in Marbury v. Madison. ''In every case we must respect the role of the Legislature, and take care not to undo what it has done.''
Putting aside for the moment the rank politics swirling around the Affordable Care Act -- the partisan grandstanding and the questions about President Obama's legacy -- consider what the law has already managed to accomplish.
It has been a remarkable success. Today, a larger proportion of working-age Americans have health insurance than at any time since record-keeping began in 1997. The number of people under 65 who were uninsured dropped to 16.3 percent in 2014, down four points from 2013. The drop was significantly greater in states that expanded Medicaid through the health reform law than in those that did not.
This is one of the things government was built to do: provide all Americans with access to quality, affordable and often-lifesaving health care. And this is what those who are determined to gut the law have been trying to dismantle. It is to the Supreme Court's credit that in this case, the majority of justices managed to stay above the politics of this issue and do their job -- which is to interpret the law Congress wrote in its entirety, not to rewrite it.
URL: http://www.nytimes.com/2015/06/26/opinion/the-supreme-court-saves-obamacare-again.html
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(The New Old Age)
October 11, 2013 Friday
Q & A: Medicare and the Insurance Exchanges
BYLINE: SUSAN JAFFE
SECTION: HEALTH
LENGTH: 1330 words
HIGHLIGHT: Seniors may be tempted to abandon Medicare for policies on the new online insurance exchanges, some state officials fear.
Shirley Mierzejewski was "very upset" when found out her Medicare health insurance premiums will nearly double next year.
"I cannot afford that, I cannot," said Ms. Mierzejewski, 77, who lives in Euclid, Ohio, and works part time as a receptionist at a local college. She has a private Medicare Advantage policy from Anthem, which provides drug and medical coverage.
"So I started thinking about the marketplaces," she said, referring to the online insurance exchanges created by the Affordable Care Act. "Maybe I could find something cheaper there."
But after attending a Medicare meeting this month at the Euclid Senior Center, she learned that the plans available on the exchanges are not intended for most people with health insurance - and that includes those with Medicare.
While thousands of Americans are trying to sign up for insurance on the exchanges, Medicare counselors like Semanthie Brooks, who spoke at the meeting Monday in Euclid, are trying to steer seniors away. They worry that Ms. Mierzejewski and other older adults may not realize that Medicare is a pretty good deal compared to exchange policies and may try to buy one anyway.
Exchange plan enrollment began on Oct. 1 and runs through March. The enrollment period for next year's Medicare Advantage and prescription drug plans - many offered by the same companies selling marketplace coverage - starts Tuesday and ends Dec. 7.
"People are going to be inundated with marketing materials and commercials around both," said Ms. Brooks, director of community advocacy at the Benjamin Rose Institute on Aging, a social service agency in Cleveland. She has been crisscrossing northeastern Ohio, helping elderly residents sort out the differences when she visits community centers, high-end assisted living facilities and subsidized senior apartment complexes. "They all want to know the impact of Affordable Care Act on Medicare," she said. "They want to know, 'Should we sign up?' "
To clear up confusion in Montgomery County, Md., officials held meetings at six centers for the elderly. "They want to know if they are better off in the exchange than in Medicare," said Leta Blank, director of the Montgomery County State Health Insurance Assistance Program. "Everyone is looking for a less expensive way to get health care."
Finding the right drug or Medicare Advantage plan can be . Dozens of plans offer different benefits and cover different drugs from different pharmacies at different prices. And you are supposed to review new plan offerings every year.
So in a year in which the insurance market is being turned upside down, here are some shopping tips for people with Medicare and caregivers.
Q.
Are the exchange plans worth looking into if you're enrolled in Medicare?
A.
No, with a few exceptions (more about that later). The state insurance exchanges are intended for people without health insurance, those who might qualify for financial assistance (subsidies or tax credits), owners of small businesses, and people who buy their own insurance. The authors of the Affordable Care Act did not anticipate that anyone with Medicare would be interested in exchange coverage. Medicare beneficiaries already get a pretty good deal, said Joe Baker, president of the Medicare Rights Center, in New York City.
The vast majority of Medicare's 52 million beneficiaries pay no premium for Part A, which covers hospitalization and other care. Premiums for Part B, for doctor visits and other outpatient services, cover only 25 percent of the program's annual cost. When the so-called doughnut hole, or gap in drug coverage, is finally closed for Part D, Medicare beneficiaries will pay only 25 percent of the average bill for prescriptions.
Q.
Do the exchanges sell Medigap plans?
A.
Alfredo Cuellar, a retired overseas development specialist in Washington, has Medicare and a supplemental, or Medigap, policy that fills in the gaps that Medicare doesn't cover, including co-payments and some deductibles. His Medigap premium is going up 20 percent next year, so he wants to look for a cheaper policy on the exchanges.
He won't find one, said Mila Kofman, executive director of the District of Columbia Health Exchange Authority. Exchanges don't sell Medigap policies. They sell comprehensive insurance that covers medical and drug costs, along with other "essential health benefits" required under the Affordable Care Act.
"It's never going to be less expensive than what a person gets under Medicare Part A and Part B," said Ms. Kofman, the former insurance commissioner of Maine.
Q.
Does Medicare coverage meet the Affordable Care Act's requirement that most adults have health insurance in 2014?
A.
Yes and no. People enrolled in premium-free Part A or a Medicare Advantage plan meet the requirement. But the relatively small number of Medicare beneficiaries who do not qualify for Part A - and have Part B only - do not meet the requirement, according to the Internal Revenue Service. In order to receive premium-free Part A coverage, you must have worked at least 40 quarters. Recent immigrants or someone who is not eligible under another person's work history (like a spouse's) will not be covered under Part A. Part B coverage alone does not meet the criteria for health insurance.
Q.
Can Medicare beneficiaries buy a plan on the exchange?
A.
No, said Leslie Fried, policy and programs director at the National Council on Aging in Washington. It is illegal for someone who knows you have Medicare to sell you duplicate coverage. The ban applies to the vast majority of people who have full Medicare coverage, as well to those who have only Part A or only Part B.
But there are some exceptions: plans on the exchange can be sold to disabled people who are eligible for Medicare but have to wait two years for coverage to kick in. Exchange plans can be sold to the very small number of people who currently pay Part A premiums; however, an exchange plan probably will ultimately cost more. And should they decide later to rejoin Medicare, these people may be subject to late enrollment penalties.
To further complicate matters, there is nothing in most insurance applications on the exchanges to prevent someone with Medicare from buying coverage. And there is nothing in the paper application, not even a warning urging Medicare beneficiaries to think twice.
"I am very worried that, without the right information, people will drop Medicare and sign up," Ms. Kofman said. The District of Columbia will be changing its eligibly screening system to prevent people with Medicare from buying coverage on the exchange, but the fix will take a while to put in place.
Medicare beneficiaries who fill out New York's online exchange application will see a special message saying they will not be eligible for premium tax credits, although other financial assistance may be available. That doesn't mean you will be sold a policy. Once the application is received, it will most likely be rejected.
Q.
Do people with Medicare need to re-enroll or get new Medicare cards?
A.
No, but some scammers have been telling the elderly that the Affordable Care Act requires them to do so. In Ohio, the state attorney general has received dozens of complaints about attempts at identity theft related to the A.C.A. and aimed at Medicare beneficiaries, said Kate Hanson, a spokeswoman for the office.
Q.
So should seniors just ignore the exchanges?
A.
No, Ms. Fried said. "They are a great excuse to call your grandchildren," she said. "Tell them to get health insurance if they don't have it."
For more information about the exchanges, visit healthcare.gov or call 1-800-318-2596. For help with Medicare, visit medicare.gov, or call 1-800-Medicare (800-633-4227) or the Medicare Rights Center (800-333-4114).
Faster Assistance for Medicare Patients
A Check on Premature Hospital Discharges
More on Preventing Hospital Readmissions
At Too Many Hospitals, a Revolving Door
Walking Away From Medicare
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June 14, 2013 Friday
Million-Anecdote Baby
BYLINE: TIMOTHY EGAN
SECTION: OPINION
LENGTH: 871 words
HIGHLIGHT: If Obamacare works, the game will be over for those doomsayers who oppose the most significant change in American life in a generation’s time.
A friend of mine has an adult child with cancer, a young man just old enough to be beyond the age of coverage under his parents' health care plan. After nearly killing him, the dreaded Hodgkin's lymphoma is in remission. But he's still a pariah in the eyes of the insurance industry, which means they can deny him a policy that might save his life.
Not for long. In six months' time, the heartless practice of refusing to let sick people buy affordable health insurance - private-sector death panels, the most odious kind of American exceptionalism - will be illegal from shore to shore.
"I can't wait for Obamacare," my friend gushed the other day. And she's not alone. About one in 10 people with cancer in this country have been denied health coverage.
The cartoon version of the Affordable Care Act, that much-loathed government takeover of one-sixth of the economy, is now moving from Beltway gasbags and caricaturists into the hands of consumers. Its fate will be determined by the countless anecdotes of people who will apply the law to their lives.
The early indications are that most Americans will be pleasantly surprised. Millions of people, shopping and comparing prices on the exchanges set up by the states, are likely to get far better coverage for the same - or less - money than they pay now. The law, as honest conservatives predicted, before they orphaned their own idea, is injecting competition into a market dominated by a few big names.
You won't hear this from the entrenched forces that have spent about $400 million denouncing the law on television ads, groups like the Karl Rove-backed Crossroads GPS. They have good reason to fear it: if Obamacare works, the game will be over for those who oppose the most significant change in American life in a generation's time. You also don't hear much from Mr. Obama himself; once again, he's a passive observer of his presidency.
But out among the states that are actively building the foundations of Obamacare, the law seems to be doing what it was supposed to do. In Washington State, nine companies have filed paperwork to offer policies in a region that has long been controlled by three big entities.
"The surprise is that, for many in the individual market, the premiums will be lower and the benefits so much richer," said Mike Kreidler, the state insurance commissioner in Washington. "Eventually, I can see the Affordable Care Act being embraced like Medicare, because once people get used to this kind of coverage, it's going to be a pretty abhorrent thing to try and take it away."
In Oregon, brisk competition will mean real choice for consumers. Starting in October, a 40-year-old resident of Portland can choose between one insurer charging $169 a month or another asking $422 for the same plan. When these rates were first posted not long ago, some of the companies requested a do-over so they could submit lower rates. Yes, lower rates. So much for a government takeover.
In California, 13 companies will compete for the business of 5.3 million or so people expected to purchase insurance through the new exchanges. Officials say the average monthly premium will be $321 - that is, $110 less than the national average predicted by the Congressional Budget Office.
All of the above are for individuals, shopping for their own health insurance as required by the new law. For the majority of Americans, those with employer coverage, Medicare or Medicaid, little will change except that insurers can no longer put a lifetime cap on benefits. The biggest change, the one likely to drive public perception, will be felt by people long denied care because of "pre-existing conditions." Soon, they will pay the same insurance rates as healthy people, and get second chances at life.
As well, there's a bonus opportunity for those stuck in jobs they hate, holding on only because they need the health care, for a take-this-job-and-shove-it moment. Moderate-income families qualify for significant bargains, using the subsidies of Obamacare.
Of course, you can expect scare stories and Fox News alerts about higher premiums. These anecdotes will focus on young, healthy people with no coverage who will have to join the rest of the country in the insurance pool, or pay a fine. Some employers will also choose to pay the government rather than insure their own workers, but you won't find too many of those listed among the best places to work. And we've already seen claims of skyrocketing premiums under the new plan, but those have been widely debunked as fraudulent comparisons between the bottom-of-the-bin teaser rates of today and the substantial packages of coverage required in the new law.
It's a fascinating moment, akin to the dawn of Social Security or Medicare. Republicans in the last three years actually did the country a favor by wildly overstating the case against a middle-ground approach to getting the United States closer to universal health care. As in 1935 and in 1965, the ossified right is warning once again of an impending end to American life as we know it. Thankfully, they're right.
Health Care's Good News
A Plan To Fix Cancer Care
We Can Be Healthy and Rich
When Paying It Forward Pays Us Back
In Medicine, Falling for Fake Innovation
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March 18, 2017 Saturday
Late Edition - Final
States Could Make Work a Medicaid Requirement Under G.O.P. Deal
BYLINE: By THOMAS KAPLAN and ROBERT PEAR; Emmarie Huetteman contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1253 words
WASHINGTON -- President Trump and conservative lawmakers in the House agreed Friday to significant changes to Medicaid that could impose work requirements on able-bodied Medicaid beneficiaries in some states and limit federal funds for the program, as Republican leaders tried to rally balking lawmakers behind legislation to repeal the Affordable Care Act.
''I want everyone to know, I'm 100 percent behind this,'' Mr. Trump said at the White House, where he met with House members in the conservative Republican Study Committee. At a news conference hours later, the president predicted, ''It's going to be passed, I believe -- I think substantially and pretty quickly.''
On Capitol Hill, the outlook was far less clear. The House is tentatively scheduled to vote Thursday to repeal President Barack Obama's signature domestic achievement, exactly seven years after Mr. Obama signed it into law. As some lawmakers came out for the measure, some others -- in the House and Senate -- were stepping forward to oppose it.
''Fundamentally, I don't believe this proposal provides an adequate market-based option for insurance access, nor does it address out-of-control costs,'' Representative John Katko, Republican of New York, said in a statement on Friday. ''Further, I am confident the proposal would harm hospitals across my district.''
The concessions to conservatives are significant -- and politically risky. The Obama administration refused to allow work requirements, saying they were not consistent with the goals of Medicaid, the health program for low-income people. Several Republican governors have expressed interest in imposing such requirements on certain Medicaid beneficiaries -- able-bodied adults without minor children.
''The Medicaid expansion has created a perverse incentive for states to provide benefits to able-bodied adults at the expense of the elderly, the blind and the disabled,'' Representative Gary Palmer, Republican of Alabama, said this week. ''A work requirement would help states focus their limited resources on the truly needy.''
The president and House conservatives also agreed to allow states to choose one lump-sum block grant to fund their Medicaid programs. The initial House bill would end Medicaid as an open-ended entitlement to health care, replacing that with an allotment to the states for each Medicaid beneficiary.
If, instead, states accepted lump-sum payments, they could gain more control over spending and more freedom to administer the program and define eligibility and benefits.
Critics say that would restrict access to Medicaid in states with conservative governments.
It is not clear how the federal government would calculate the amount of block grants. Nor is it clear which states, if any, might accept that option.
The nonpartisan Congressional Budget Office has already estimated that, under the House bill, the number of people without health insurance would be 14 million higher than expected next year and would be 24 million higher by 2026. The Medicaid adjustments could nudge that number even higher, a problem for many senators.
The one Republican senator up for re-election next year in a true swing state, Dean Heller of Nevada, said on Friday that he opposed the bill in its current form. Another Republican senator, Joni Ernst of Iowa, was noncommittal.
Another likely change, Republicans said, would be to restructure the tax credits offered under the bill to help people buy private health insurance. Republican lawmakers had expressed concern that the tax credits, as originally devised by House leaders, were insufficient and could produce huge increases in premiums for some people age 50 to 64.
The changes in Medicaid provisions of the bill could help win over conservative House members who have expressed concern or outright opposition to the bill for multiple reasons. Mr. Palmer voted against the House bill in the Budget Committee on Thursday. On Friday, he emerged from the White House in favor of it.
''We've never had an opportunity to do anything like this,'' Mr. Palmer said later. ''This will be the most significant entitlement reform that we've seen.''
Representative Mark Walker of North Carolina, the chairman of the Republican Study Committee, said other members were on board as well. ''On balance and with the changes we agreed to in the bill's final text, I can vote for it,'' he said after the meeting in the Oval Office.
Mr. Trump's level of engagement has been a major question mark as congressional leaders have tried to sell the proposal in the face of stinging opposition from a number of directions. His show of support for the House plan on Friday provided a lift for House leaders, who have been on the defensive all week over their bill and the persistent conservative opposition to it.
Conservative holdouts who still have objections to the bill may reconsider if they come under more pressure from the president.
''These changes definitely strengthen our number, but also show that President Trump's all-in now,'' said the House majority whip, Representative Steve Scalise of Louisiana, who was at the White House meeting and recounted how Mr. Trump voiced his support for the measure.
Representative Bradley Byrne, Republican of Alabama, said the changes in the bill were having the intended effect. ''I can tell you, from the private conversations I'm having with people, support for the bill has built dramatically over the last 24 hours,'' he said Friday.
But the changes were not enough to sway the hard-right House Freedom Caucus, which reiterated its opposition on Friday. Changing the bill to win over such conservatives risks alienating more moderate members of the House and the Senate who worry that the measure could cause millions of people to lose health coverage.
The Republican governors of four states that have expanded Medicaid under the Affordable Care Act -- Arkansas, Michigan, Nevada and Ohio -- sent a letter to congressional leaders this week rejecting the House bill as written.
Senator Susan Collins, Republican of Maine, said on Thursday that she opposed the House bill, explaining that it would not do enough to help low-income older people afford insurance. ''We don't want to in any way sacrifice coverage for people who need it the most,'' she told The Portland Press Herald.
House Republican moderates may be loath to take a difficult political vote if they are convinced the measure will die in the Senate.
''If I hear one more senator tell me that this is dead on arrival, I think my head's going to explode,'' said Representative Charlie Dent, a moderate Republican from Pennsylvania. ''That certainly is not something many members of the House find very appetizing -- voting for something that will go nowhere in the Senate.''
The House Democratic whip, Representative Steny H. Hoyer of Maryland, predicted that while the bill might be approved by the House, ''It will not become law.''
Under the Affordable Care Act, 31 states have expanded Medicaid, providing coverage to millions of adults. The federal government has been paying more than 90 percent of the costs for the newly eligible beneficiaries. Republicans say this has taken the program away from its original purpose.
Democrats contend that work requirements could increase the number of uninsured, limiting access to health care without significantly increasing employment.
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URL: http://www.nytimes.com/2017/03/17/us/politics/trump-congress-affordable-care-act-medicaid.html
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GRAPHIC: PHOTOS: Members of the conservative House Republican Study Committee met with President Trump, far right, at the White House on Friday to discuss their proposal to replace the Affordable Care Act. (PHOTOGRAPHS BY STEPHEN CROWLEY/THE NEW YORK TIMES)
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December 28, 2016 Wednesday 00:00 EST
Vivek Murthy Thinks We Need to Learn How to Deal With Stress;
Talk
BYLINE: Interview by ANA MARIE COX
SECTION: MAGAZINE
LENGTH: 661 words
HIGHLIGHT: The surgeon general on the Affordable Care Act, the historic campaign to curb tobacco use and whether or not the president takes his advice.
Why does the surgeon general wear a uniform? I wear the uniform of the U.S. Public Health Service Commissioned Corps, which evolved from a Marine hospital system headed by a supervising surgeon, later given the title of surgeon general. I like the uniform: There was a time when my friends wouldn't let me leave the apartment without somebody first checking to make sure I wasn't going to embarrass the group with what I was wearing, so having the uniform is helpful.
Your term as surgeon general will span two presidents: first, a president with a smoking habit, and soon a president who does not seem to be a particularly wellness-focused person. Is it harder for you to do your job when your own boss doesn't take your public platforms to heart? My job is to be a voice for public health for the country and to do so based on science, not based on what other folks might be doing within the administration. We all have our challenges.
Would you ever try to keep the president healthy by recommending, for example, a walking desk in the Oval Office? I think that'd be a great idea as long as it was agreeable to the incoming president.
The Office of the Surgeon General's campaign to curb tobacco use in the 1960s is widely cited as one of greatest modern public-health successes, but I wonder if that's a fluke? We haven't seen similar success in subsequent efforts to reduce obesity or encourage exercise, and they've been going on just as long - we're still pretty unhealthy as a whole. With smoking, we started moving toward a norm where tobacco use was no longer cool - that was a cultural shift that we made in part through media and community-driven campaigns. That's what we have to do with nutrition and physical activity, too. The environment and culture are extremely important in determining the choices that people make, and when paired with solid education programs, they can help us make the lifestyle changes that are really tough.
You were an early proponent of the Affordable Care Act. You co-founded an organization, Doctors for America, that's dedicated to expanding affordable health care. What should we keep in mind about the A.C.A. as we head into this new administration? At the end of the day, what we should really care about is both coverage and the value of care that's delivered. The A.C.A. is not perfect, but it has helped us move forward. When I think about some of the challenges that we face today, particularly substance-use disorders and addiction - addressing these challenges requires people to have health-insurance coverage. I want to make sure that as we go forward, we don't lose the gains we've made.
You're among the first surgeons general to consider emotional wellness the "third pillar of health," alongside physical and nutritional wellness. Science tells us more and more now that there is a strong connection between emotional well-being and health outcomes, and that you can proactively cultivate emotional well-being through relatively simple practices like sleep, social connection and meditation. Stress is an epidemic in our country, and sometimes people turn to unhealthy methods of dealing with it, whether it's unhealthy foods, or drugs and alcohol, or violence.
I read an article you wrote when you were a medical student, and you said: "Understanding who you are and who you are becoming through your experiences is the single most important part of medical training and practice." Who have you become through your experiences as surgeon general? I have come to believe that America is a promise we have made to one another. I have never felt more inspired to be part of upholding this ideal, because in the faces and the stories of the people that I've met all around the country, I have found people who are worth fighting for.
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Interview has been condensed and edited.
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August 21, 2014 Thursday
Late Edition - Final
Why More People Might Get Health Insurance From Work
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; THE NEW HEALTH CARE; Pg. 3
LENGTH: 799 words
In an earnings call last week, Walmart announced that its workers were signing up for health insurance en masse. The news was bad for the company's shareholders, since the added $500 million it will cost to cover them will eat into expected profits. But it also means that many more low-income families have health insurance now than did last year.
The change didn't come because of a more generous company policy. Walmart has long offered health insurance to its full-time workers for relatively low premiums -- about $18 every two weeks for its lowest-paid workers. It came because many more workers decided to take advantage of the offer.
It's early yet to be sure of a strong trend, but the Walmart experience mirrors evidence from early polls and the historical experience of Massachusetts, which enacted a law similar to the Affordable Care Act in 2006. More people may be signing up for employer-based coverage than did before.
When we talk about the effect of the Affordable Care Act on health insurance, we often focus on people who were shut out of the market before, either because a prior illness made insurance inaccessible to them or because a high premium put coverage out of their financial reach. What Walmart's experience reminds us is that there were also uninsured people who simply chose not to buy coverage before there was a law requiring them to do so. Now they may be changing their minds.
This increase, if it is permanent, is going to cost employers money. But it illustrates how the Affordable Care Act is set up to build on the country's existing insurance system rather than tear it down. The law doesn't just create new public insurance programs. It also includes incentives designed to get more people enrolled in employer health coverage.
The law's best-known and least-liked provision -- the ''individual mandate'' -- is probably causing the trend. For the first time, people must buy insurance this year or be subject to a tax penalty. In Massachusetts, a similar requirement changed the employer-sponsored insurance market in two ways, said Sharon Long, a senior fellow at the Urban Institute, who has studied the state's experience.
First, it encouraged more workers who were already being offered health insurance to take it -- an effect roughly analogous to what Walmart is experiencing. Second, it actually induced more employers to offer coverage to their workers -- because, Ms. Long believes, workers began to demand insurance once they were required to have it. Over all, the percentage of Massachusetts residents with employer-based insurance went to 65.6 percent in 2008, when the health care law was up and running, up from 61 percent in 2006.
The first effect should apply nationwide. The second may be a quirk of the Massachusetts labor market, where health reform was broadly popular, and most businesses tend to pay high wages. Estimates from the Congressional Budget Office suggest that some small employers that currently offer insurance may stop doing so now that their workers have other options. Some analysts of the law (and many of its critics) forecast widespread employer ''dumping'' of workers into new health insurance marketplaces, but there's little evidence so far that this is happening. The law includes a requirement that employers offer coverage to their workers or pay a fine, but the Obama administration has postponed its start.
So far, at least, more people seem to be getting health insurance from their jobs than did last year. A recent analysis of Gallup polling data, published in The New England Journal of Medicine, found that while most newly insured people got coverage through Medicaid or new state insurance marketplaces, about 2 percent of the increase was coming from other sources. The employer market is not the only possible source of that rise, but Dr. Benjamin Sommers, a professor at the Harvard School of Public Health who wrote the paper with colleagues, said it suggests movement in employer coverage. Recent surveys from the Urban Institute also show an increase in the number of people reporting employer-based coverage, Ms. Long said, though the change was small enough that it could be a result of sampling errors.
A pair of employer surveys from the Federal Reserve Bank of New York found that employers were expecting ''a somewhat larger proportion of employees, on net, would be covered than in the past.''
Dave Ostendorf, a managing director at Towers Watson, a benefits consulting firm, said his customers were seeing small but real increases in the number of people they're insuring through employer plans this year. It's early to be sure, he said, but he's seeing indications that employer coverage is growing.
''The individual mandate is new, and that's something that people are aware of,'' he said.
URL: http://www.nytimes.com/2014/08/21/upshot/why-more-not-fewer-people-might-start-getting-health-insurance-through-work.html
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GRAPHIC: PHOTO: Walmart employees at a meeting in Fayetteville, Ark., in June. The company announced that many more of its workers had signed up for its health insurance. (PHOTOGRAPH BY RICK WILKING/REUTERS)
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April 15, 2014 Tuesday
Late Edition - Final
Budget Office Lowers Estimate for the Cost of Expanding Health Coverage
BYLINE: By ANNIE LOWREY
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 628 words
WASHINGTON -- The insurance expansion under the Affordable Care Act will cost $1.383 trillion over the next decade, more than $100 billion less than previous forecasts, the Congressional Budget Office said Monday.
The nonpartisan budget office's report, an update to projections from February, shows the law costing less than in previous estimates in part because of the broad and persistent slowdown in the growth of health care costs. The news might come as welcome to Democrats on Capitol Hill and in the White House who are struggling to defend the law in an election year.
''Today's C.B.O. update shows once again that the Affordable Care Act will help reduce our deficits while offering more Americans access to quality, affordable health care,'' said Senator Patty Murray, Democrat of Washington and the head of the Senate Budget Committee. ''We need to keep building on this progress rather than turning back the clock on the millions of people who have now signed up for coverage.''
The reduced estimate is attributable mostly to the budget office's cutting its projections of federal spending for subsidies for insurance premiums, with estimates falling by $3 billion for spending in 2014 and $164 billion over 10 years.
The budget office also issued projections that 12 million more nonelderly people would have insurance in 2014 than would have otherwise, rising to 26 million in 2017. The budget office, making projections along with the Joint Committee on Taxation, said the number of uninsured people would drop to 30 million in 2017 from 42 million in 2014.
The budget office and tax committee estimate that ''the insurance coverage provision of the A.C.A. will increase the proportion of the nonelderly population with insurance from roughly 80 percent in the absence of the health care law to about 84 percent in 2014 and to about 89 percent in 2016 and beyond,'' the report said.
In addition, the C.B.O. trimmed its estimates of the penalties that individuals would pay for failing to purchase coverage and that businesses would pay for refusing to cover their employees. It estimates that individuals will make $46 billion in payments over a decade, and employers $139 billion.
Despite the significant costs of the insurance expansion, the budget office said that over all, the Affordable Care Act should reduce deficits.
In a separate report, the budget office also trimmed its estimate of this year's fiscal deficit. In the 2014 budget year, it forecasts the government's shortfall to be $492 billion, or about 2.8 percent of economic output. In February, the budget office had estimated that the deficit would be about $23 billion higher.
The smaller deficit projection is a product of lower outlays for discretionary programs and net interest payments, the budget office said. It also cut its estimate of the cumulative deficit from 2015 through 2024 by $286 billion.
In the past five years, the deficit has fallen precipitously because of the economic recovery, spending cuts and tax increases. The budget office projects the deficit to fall by a third between last fiscal year and this fiscal year alone.
For years during the recession and sluggish recovery, the federal government racked up trillion-dollar deficits, and in the 2009 fiscal year -- during the worst of the downturn -- the deficit was equivalent to nearly 10 percent of economic output.
But the budget office said deficits would soon start rising again as an aging population required more health care and Social Security spending and as the government paid out more interest on the national debt. The budget office forecasts deficits to swell by the mid-2020s to about 4 percent of economic output, with the federal debt climbing to 78 percent of economic output, up from 72 percent today.
URL: http://www.nytimes.com/2014/04/15/us/politics/budget-office-lowers-estimate-for-cost-of-expanding-health-coverage.html
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December 12, 2013 Thursday
Late Edition - Final
Dropping Health Plans, To Pick Better Coverage
BYLINE: By STACY COWLEY
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1
LENGTH: 1311 words
For nearly 20 years, Keith Perkins offered health insurance to employees of his small electrical contracting company in Greencastle, Pa., and footed most of the bill. This year, with the arrival of the Affordable Care Act's insurance marketplace, he decided to stop.
Mr. Perkins, who is 54, did the math and calculated that most of his employees, who are spread across Maryland, West Virginia and Pennsylvania, would come out ahead if he dropped his group policy and let them buy insurance individually through the new federal and state exchanges.
He knew the move would be unpopular with some employees, but he was tired of trying to choose one plan every year to cover all of their diverse needs.
''Some of my guys are on the lower end of the wage scale,'' said Mr. Perkins, who typically has 10 to 18 employees. ''When I did the subsidy calculator, I realized many of them would actually be better off if we didn't offer coverage. We took the amount of money we were paying for health insurance and dumped it into their paychecks instead. And this way, they get to make the choice, not me.''
America's smallest employers, those with fewer than 50 workers, are not required under the Affordable Care Act to offer insurance or contribute to their employees' health care costs. As a result, some companies, seeing that their employees now have attractive options at Healthcare.gov, are seizing the opportunity to wash their hands of one of their most expensive business problems.
''It's a question we get every single day,'' said Thomas Harte, an insurance broker with Landmark Benefits in Hampstead, N.H. ''Employers are seriously considering walking away from their plans.''
The decline in the number of small businesses offering health insurance began long before the new law. In 2011, 38 percent of American companies with fewer than 50 workers provided health insurance, down from 47 percent a decade earlier, according to a study by the Robert Wood Johnson Foundation.
It is too early to say how the Affordable Care Act will affect that trend, but health insurance has long been a headache for small businesses. Their policies are typically more expensive than comparable plans available to larger employers, and because the risk pool of participants is tiny, one sick employee can increase a group's premiums sharply.
Nancy Smith, 62, struggles every year to find affordable coverage for herself and for three employees at the Great Arizona Puppet Theater, an arts organization in Phoenix. When one employee developed diabetes several years ago, the group's annual premiums rose 100 percent. That prompted Ms. Smith, chief executive and artistic director, to cut costs by switching to a bare-bones plan offering catastrophic coverage with a high deductible.
Now, though, that plan is being canceled because it does not meet the new law's minimum standards, so she intends to sit down with her employees to shop on Healthcare.gov for individual coverage. She put off looking while the site's technical problems were being addressed, but she likes what she has seen. ''It looks like we're all going to get better coverage and save money in the long run,'' she said.
Kelly Fristoe, an insurance broker in Wichita Falls, Tex., estimates that the employees at nearly half of his small-group clients would be better off if the companies dropped their coverage, gave some of the savings directly to the workers and let them shop for their own insurance. Four clients have already decided to do that for 2014.
Steve Hooper, president of the Health Economics Group, a Rochester, N.Y., company that manages corporate benefit plans, said many of the workers in his region, including most of his own employees, have incomes low enough to qualify for the federal subsidies available to those who earn up to four times the federal poverty level, about $46,000 annually.
''We have a lot of part-time people and single moms with kids,'' Mr. Hooper said. ''The New York exchange offers some tremendous options for them that are better than anything else out there.''
A self-described data fanatic, Mr. Hooper, 74, spent months studying the law's nuances and exploring various situations for his 25-person business. He knew what he paid his employees, but he did not know their overall household incomes. So he created a staff survey and arranged meetings with his employees to discuss their individual situations.
It became clear that many, especially those with children, would be better off without the option of buying company-sponsored insurance. Employees who have access to an ''affordable'' employer plan can buy a plan instead through the exchanges if they choose, but they cannot collect any subsidy that they would otherwise be eligible for. And those with children face an extra pitfall: The law's calculation of ''affordable'' does not take into account the cost of adding dependents to the employer's plan.
In 2013, to insure 11 workers, Mr. Hooper's company contributed $283 a month for each employee toward health care premiums, covering more than 80 percent of the cost for an individual. Employees paid an additional $55 a month, or more if they needed coverage for dependents. For 2014, Mr. Hooper is taking the $30,000 to $40,000 he will save by canceling the group's plan and using it to fund flexible spending accounts for each employee.
So far, he said, only one person is facing higher premiums, and he plans to add extra money to her flexible spending account to fill the gap. And while his company's old plan carried a $2,500 annual deductible, he said the typical deductibles on his employees' new plans range from zero, for those who qualify for Medicaid, to $2,000.
Taxes, however, are a concern. Workers on an employer-sponsored plan pay their share of their monthly premium with pretax dollars. Plans bought through the exchanges are paid for with after-tax wages, which can add significantly to the cost born by employees. But Mr. Hooper said the combination of subsidies and lower deductibles would still reduce overall spending on health care for nearly all of his employees.
''When you do the math,'' he said, ''it's pretty clear that in our particular case, everyone is going to benefit if we get out of the insurance business.''
Paul Hamborg isn't sure. Mr. Hamborg is trying to decide whether his company, Enrollment Research, a consulting firm based in San Antonio, should renew its group insurance in 2014. None of the company's five employees would qualify for subsidies individually, and he is weighing the advantages of switching to individual coverage -- more choice for his employees, less administrative overhead for him -- against the increased tax bills for them. That issue, said Mr. Hamborg, who is 40, ''is the one thing about the Affordable Care Act that's a real disappointment, from my standpoint.''
Brokers say they expect 2014 to be a wait-and-see year in the small-business market. Many carriers offered early renewal options this year, and a lot of businesses took advantage of them to buy time while the new system gets off the ground.
Mr. Harte, the insurance broker in New Hampshire, said many of his customers were exploring dropping insurance, but tentatively -- in part because they worry that it would look bad even if their employees came out ahead. ''Most employers don't want to be the first one to cancel their health insurance coverage within their competitive marketplace,'' he said.
Mr. Perkins, the electrical contractor, acknowledges that dropping the benefit had its costs. Some employees are now paying more for coverage, and some have quit.
''At least part of the reason they left was the lack of health insurance here now,'' he said, adding, ''We have also hired seven new employees this year and didn't have a problem finding them.''
In the end, he said, the financial savings and the administrative savings were worth it.
URL: http://www.nytimes.com/2013/12/12/business/smallbusiness/changing-the-health-insurance-equation-for-small-employers.html
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GRAPHIC: PHOTO: Steve Hooper, of the Health Economics Group, a company that manages corporate benefit plans, says most of his employees have incomes low enough to receive federal subsidies. (PHOTOGRAPH BY BRENDAN BANNON FOR THE NEW YORK TIMES) (B2)
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The New York Times
July 1, 2014 Tuesday
The New York Times on the Web
Questions and Answers on the Contraceptives Case
BYLINE: By ADAM LIPTAK
SECTION: Section ; Column 0; National Desk; Pg.
LENGTH: 681 words
WASHINGTON -- The Supreme Court on Monday is expected to rule on a pair of challenges to a part of President Obama's health care law that requires many employers to provide insurance coverage for contraceptives. Here is a look at the parties, the lawyers and the issues in the case.
Q. Who are the challengers?
A. The cases were brought by two corporations whose owners say they try to run their businesses on religious principles. One is Hobby Lobby, a chain of crafts stores. The other is Conestoga Wood Specialties, which makes wood cabinets. In March, the justices heard a consolidated argument in the two cases, Burwell v. Hobby Lobby Stores, No. 13-354, and Conestoga Wood Specialties v. Burwell, No. 13-356.
Q. Who argued the cases?
A. Paul D. Clement, a United States solicitor general in the Bush administration, argued for the companies. The current solicitor general, Donald B. Verrilli Jr., represented the government. The two men had faced off two years ago in another challenge to the Affordable Care Act, which focused on its requirement that most Americans obtain health insurance or pay a penalty. The court ruled for the Obama administration in that case by a 5-to-4 vote.
Q. What does the challenged law say?
A. A provision put in place under the Affordable Care Act requires many employers to provide female workers with comprehensive insurance coverage for a variety of methods of contraception.
Q. Does the law apply to all employers?
A. No. Under the law and related regulations, small employers do not need to offer health coverage at all; religious employers like churches are exempt; religiously affiliated groups may claim an exemption; and some insurance plans that had not previously offered the coverage are grandfathered. Last June, a federal judge in Tampa, Fla., estimated that a third of Americans are not subject to the requirement that their employers provide coverage for contraceptives.
Q. How does the administration justify the law?
A. In his briefs, Mr. Verrilli told the justices that requiring insurance plans to include comprehensive coverage for contraception promotes public health and ensures that ''women have equal access to health care services.'' He added that doctors, rather than employers, should decide which form of contraception is best. A supporting brief from the Guttmacher Institute, a research and policy group, said that many women cannot afford the most effective means of birth control, and that the law will reduce unintended pregnancies and abortions.
Q. What is the companies' objection?
A. They say that some contraceptive drugs and devices are tantamount to abortion because they can prevent embryos from implanting in the womb. Providing insurance coverage for those forms of contraception would, they say, make them complicit in the practice. They said they had no objection to other forms of contraception approved by the Food and Drug Administration, including condoms, diaphragms, sponges, several kinds of birth control pills and sterilization surgery.
Q. Do for-profit companies and their owners have the right to object on religious grounds?
A. The lower courts are divided over whether for-profit corporations have rights under the First Amendment's free exercise clause and the federal law at the heart of the contraceptives case, the Religious Freedom Restoration Act of 1993. In weighing the question, the Supreme Court may have considered whether its 2010 decision in Citizens United, which said corporations have free speech rights under the First Amendment, suggests that they also have the right to religious liberty.
Q. What is the Religious Freedom Restoration Act?
A. The law was a response to a 1990 Supreme Court decision that declined to recognize religious exceptions under the First Amendment's free exercise clause to generally applicable laws. Congress effectively reversed that decision. ''What this law basically says,'' President Bill Clinton said before signing the bill, ''is that the government should be held to a very high level of proof before it interferes with someone's free exercise of religion.''
URL: http://www.nytimes.com/2014/07/01/us/a-look-at-the-parties-and-the-issues-in-the-hobby-lobby-case.html
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The New York Times
October 8, 2014 Wednesday
Late Edition - Final
30,000 Lose Health Care Coverage at Walmart
BYLINE: By HIROKO TABUCHI
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 9
LENGTH: 703 words
Walmart Stores, the world's largest retailer and the nation's largest private employer, said on Tuesday that it would terminate health insurance coverage for about 30,000 part-time workers, joining a string of retailers that have rolled back benefits in response to the Affordable Care Act.
Starting on Jan. 1, Walmart will no longer offer insurance to employees working less than an average of 30 hours a week, a move the retailer said was in response to an unexpected rise in health care costs.
''This year, the expenses were significant and led us to make some tough decisions,'' Sally Welborn, Walmart's senior vice president for global benefits, said in a blog post announcing the changes.
The workers losing their coverage make up about 5 percent of the company's part-time work force of about 600,000, including in-store, logistics and corporate workers, said Brooke Buchanan, a company spokeswoman. Walmart did not disclose what percentage of the part-time work force would be left without coverage. Many part-time employees were never covered for a variety of reasons.
Over all, Walmart employs about 1.3 million people in the United States, and provides health coverage to about 1.2 million workers and workers' family members, Ms. Buchanan said.
In scaling back coverage for part-time employees, Walmart joins retailers including Home Depot, Target and Trader Joe's, which have dropped benefits in response to the Affordable Care Act, the health care overhaul enacted by the Obama administration. In 2011, Walmart eliminated health insurance for employees working fewer than 24 hours a week.
The company said that the health law's introduction had prompted larger-than-expected numbers of employees to enroll in its health plans, driving up expenses.
The retailer expects to spend an additional $500 million on health care costs in the United States this year, it said in a filing in August, far more than the $330 million increase it forecast in February.
The Affordable Care Act, the most comprehensive overhaul of the nation's health care system in decades, requires most Americans to enroll in health insurance or face a tax penalty. From Jan. 1, 2015, it will require companies with 50 or more employees to offer health insurance coverage to employees working at least 30 hours a week, or pay a penalty.
Employees working less than that can apply for subsidies in new government-run insurance exchanges that opened last year. But some experts say that the exchanges make it easier for employers like Walmart to eliminate health care coverage for part-time workers.
Walmart said that it would work with a health coverage specialist to guide workers through the process of finding alternative coverage.
It also said that it would raise health insurance premiums in 2015. But it said that its premiums remained lower than the industry average, citing figures from the human resources consulting firm Aon Hewitt. Representatives at Aon Hewitt were not immediately available to confirm that.
Stuart Appelbaum, president of the Retail, Wholesale and Department Store Union, called Walmart's move ''shameful.''
''Not only do they deny their workers full-time jobs, now they're denying them health care coverage,'' Mr. Appelbaum said.
Still, health benefits for part-timers are the exception rather than the rule among retailers. Last year, 62 percent of large retail chains offered no health care benefits to their part-time workers, up from 56 percent in 2009, according to the New York-based consulting firm Mercer.
Beth Umland, Mercer's director of research for health and benefits, said that more retailers were likely to eliminate health care coverage for part-timers. ''Now employees can go somewhere else to get coverage,'' she said. ''It's an easier decision to make than before.''
Nancy Reynolds, 67, who has worked part time at the Walmart store in Merritt Island, Fla., for the last six years, said she worried that losing her insurance would mean higher costs for treatment of her diabetes, glaucoma and arthritis. Ms. Reynolds is covered by Medicare, but she said that she relied on company coverage to supplement it.
''I depend on Walmart's health care,'' Ms. Reynolds said. ''I'm not sure what I'm going to do.''
URL: http://www.nytimes.com/2014/10/08/business/30000-lose-health-care-coverage-at-walmart.html
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(Economix)
June 27, 2012 Wednesday
Alternatives to the Mandate
BYLINE: EDUARDO PORTER
SECTION: BUSINESS; economy
LENGTH: 687 words
HIGHLIGHT: Even if the key provision of the health care act is overturned, there may be more effective ways to keep premiums from rising sharply and encourage healthy Americans to buy insurance.
The Supreme Court is expected to decide imminently on the constitutionality of the health care act. Many people, ordinary citizens and legal experts, think it will strike down the mandate that all Americans buy health insurance.
In last week's column I posited that this might not matter because many healthy Americans would quite likely have ignored the mandate anyway. But there is a better reason for President Obama not to despair over the prospect: absent a mandate, there are other ways, perhaps more effective, to keep premiums from rising sharply and encourage healthy Americans to buy insurance.
The Obama administration put a mandate in the Affordable Care Act because the law requires insurers to charge the same premium regardless of health status. Without a mandate, it would make sense for the healthy to drop their insurance until they got sick and needed it. But if only the unhealthy bought insurance, premiums could rise sharply to cover insurance companies' higher costs. At the extreme, this could blow up the insurance market altogether.
There is another way to keep premiums from escalating, however. Rather than force the healthy to buy policies from the insurance exchanges set up under the new law, give the unhealthy other, better options so they don't have to obtain health insurance from the exchanges.
New York offers an interesting precedent. In the early 1990s, like many other states, it tried to make it easier for the sick to buy health insurance by requiring insurers in the individual and small-group market to charge the same regardless of people's health. The consequences -- sharply rising premiums and shrinking insurance rolls - were predictable.
In some states, similar moves impaired the insurance market. Kentucky was left with only one private insurer. In New York, however, the market rebounded in the late 1990s, when premiums declined and insurance rolls started rising again.
According to Jeffrey Clemons, an economist at the Stanford Institute for Economic Policy Research, a key reason was New York's aggressive expansion of Medicaid to cover the "medically needy," which drew in more relatively unhealthy New Yorkers. A few other states also tried similar strategies to New York's.
Mr. Clemons estimated that requiring insurers to charge the same regardless of health status cut the share of the public covered by private insurance by 8 to 11 percentage points within three years. But expanding Medicaid to an additional 6 percent of adults -- to cover the relatively unhealthy -- led to an increase of 5 percentage points in coverage by private health insurance.
A back-of-the-envelope estimate by Mr. Clemons concluded that the expansion of Medicaid in many states -- taking advantage of "demonstration waivers" from the federal government that allowed them to experiment with eligibility rules -- held down premiums of those with private insurance by an average of roughly $1,700 per year for a family of four.
All of this indicates that insurers -- relieved of the pressure to cover the least healthy among the previously uninsured -- lowered premiums enough that others, not benefiting from Medicaid, could afford to purchase policies in the private market.
This kind of strategy would not necessarily be cheap. Medicaid takes a very large share of New York's budget. But it might not be as expensive as the alternative. If the Supreme Court strikes down the mandate, premiums will rise as healthy Americans start dropping their health coverage. So will the government subsidies for low-income Americans to buy insurance. The Rand Corporation estimated that average government spending for newly insured people will almost double, to $7,468.
By pushing down premiums on the private health insurance market, expanding Medicaid would alleviate some of these costs. Most importantly, perhaps, it would address the enormous social costs of the medically uninsured.
The Supreme Court and the National Conversation on Health Care Reform
Further Reading on Mr. Mandate
First the Mandate, Then All Tax Incentives
Awaiting the Supreme Court's Health Care Ruling
Define 'Welfare State,' Please
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The New York Times
August 26, 2016 Friday
Late Edition - Final
The Growing Pains of Obamacare
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 18
LENGTH: 441 words
To the Editor:
Re ''Obamacare Hits a Bump'' (column, Aug. 19):
As a former insurance regulator, I can't share Paul Krugman's faith in health insurers. Mr. Krugman's latest prescription for what ails the Affordable Care Act is to give insurers even more taxpayer dollars, both in the form of greater premium assistance to consumers and risk subsidies to the insurers themselves. He also suggests that government step up its efforts to force healthy (young) consumers to buy insurance.
The fact is that millions of Americans are making a rational decision to reject a bad product. Premiums are often the least of your health insurance costs; skyrocketing deductibles -- for which no subsidies are available -- make it impossible for so many to even use their insurance. Moreover, narrow networks limit consumer options so that even cancer treatment may be out of network.
Unless such issues are addressed, Mr. Krugman will not be joined in his Affordable Care Act cheerleading by consumers.
BRENDAN WILLIAMS
Bedford, N.H.
To the Editor:
Paul Krugman notes that many more people are now insured under Obamacare, people who ''turn out to have been sicker and more in need of costly care than we realized.'' Many of those people, but for Obamacare, would have either died or made repeated use of emergency care. Let us take that into account when we do the cost calculations.
CONSTANTINE KARALIS
Brooklyn
To the Editor:
Re ''U.S. Prepares Enrollment Push as Insurers Balk on Health Law'' (front page, Aug. 18):
How many times must it be demonstrated that health care cannot be treated like any other market commodity before our legislators get the point? This article once again confirms that affordable health care can't be delivered using a private, for-profit system.
One cannot make a profit insuring sick people. Therefore, health insurance companies are most profitable when they avoid sick people while continuing to collect premiums from healthy customers. When this does not work, raising prices is necessary to keep profits up.
But health insurance premiums are already unaffordable for most of us. That is why the young and healthy are not buying. The only way to make health care affordable is to have everyone paying into the pot in proportion to their income while eliminating the unnecessary expensive middleman: health insurance companies.
Must we wait until only the billionaires will be able to afford health care before we join all the other industrialized countries and switch to such a government-funded single-payer system (Medicare for All)?
ELIZABETH R. ROSENTHAL
Larchmont, N.Y.
The writer is a dermatologist.
URL: http://www.nytimes.com/2016/08/26/opinion/the-sticking-points-in-obamacare.html
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The New York Times
February 13, 2017 Monday
Late Edition - Final
For Democrats, Being Out of Power Has Its Perks
BYLINE: By EMMARIE HUETTEMAN
SECTION: Section A; Column 0; National Desk; CONGRESSIONAL MEMO; Pg. 9
LENGTH: 883 words
BALTIMORE -- There is something liberating about not being in charge.
House Democrats seemed jovial, occasionally even buoyant, last week as more than 140 members of their caucus gathered for a retreat in a hotel overlooking Baltimore's Inner Harbor, unencumbered by the raucous protests and heavy expectations that followed Republicans to their own retreat in Philadelphia two weeks ago.
As some of their conservative colleagues received a battering at town hall meetings back home over issues like their plan to repeal the Affordable Care Act, Democrats tried not to look too pleased with the consolation prize from a bruising election: It is not their problem anymore.
''What they're realizing is that disaster, that marketplace chaos which would result from repealing and replacement, is going to be blamed on them,'' Representative Frank Pallone Jr. of New Jersey, the top Democrat on the House Energy and Commerce Committee, said of Republicans and their proposals for the health law. ''And they can't blame us for it anymore.''
Eight years ago, it was Democrats who settled into a defensive crouch as they weathered their own town hall gatherings, fending off criticism from Republicans and the nascent Tea Party movement.
But with the transfer of power from President Barack Obama to President Trump last month, giving Republicans control of both the White House and Congress, came the transfer of responsibility. Republicans who spent the Obama years casting symbolic votes to repeal the Affordable Care Act, knowing they would die on the Resolute Desk, are now wrestling with the monumental challenge of actually producing a comprehensive replacement.
For House Democrats, the immediate challenges are less pressing. Any debate about whether to cooperate with the weeks-old Trump administration is strictly hypothetical, as Mr. Trump has yet to push for any legislative priorities, such as his promised trillion-dollar infrastructure plan.
''He's a sideshow,'' said Representative Eric Swalwell of California. ''Until he shows he wants to work for the American people, he's irrelevant.''
Spared the pressure to emerge with a detailed policy plan, Democrats arrived in an unseasonably warm Baltimore on Wednesday, tumbling off coach buses onto which they had been assigned alphabetically like schoolchildren on an outing. After hours of discussions, they scattered for late-afternoon excursions on Thursday to the aquarium, the art museum or the deserted ballpark. They took selfies on Friday with Chelsea Handler, the outspoken comedian, who closed out their retreat.
There was time for semantic debates: It was not a ''retreat,'' leaders insisted, because they are not ''in retreat.''
''Joe aptly named the retreat -- issues conference, pardon me, I stand corrected,'' said Representative Linda T. Sánchez of California, vice chairwoman of the House Democratic Caucus, referring to the chairman, Representative Joe Crowley of New York.
''Joe aptly named the issues conference 'Fighting for All Americans,''' Ms. Sánchez started again with a mischievous look. ''I kind of dubbed it in my own language as 'Kicking a Little Ass for the Working Class.'''
(''Yea!'' Representative Nancy Pelosi of California, the Democratic leader, interjected, clapping and laughing.)
There was occasion for jokes: Asked about the strategy sessions, Mr. Crowley made a playful reference to Mr. Trump's effort at his first news conference as president to demonstrate that he had separated himself from his companies.
''We're going to bring in the pallets with all the stacks of paper of the strategy, coming in now,'' he said.
And there was ample opportunity to reflect on the election that delivered Mr. Trump his surprising victory -- though it did gain them a handful of seats, as they are quick to point out -- and a strategy for capitalizing on Mr. Trump's missteps and pulling themselves out of the minority in the House, where they have been relegated since 2011.
With appearances by a handful of activists, including Tamika Mallory, one of the organizers of the Women's March on Washington, Democrats contemplated how they could prevent people from becoming desensitized or disheartened by a near-constant flow of contentious moves by the White House.
But others talked about how to reach out to those who may not feel compelled to wave signs on the National Mall. Representative Cheri Bustos, whose northwestern Illinois district Mr. Trump narrowly won, said Democrats understood the concerns about wage stagnation, student loan debt and other economic issues that drove people to vote for him. But she said she worried about Democrats' ability to communicate with those voters.
''For God's sake, we cannot talk down to people,'' she said.
By Friday morning, even as they applauded an appeals court ruling that upheld the suspension of Mr. Trump's executive order on immigration, Democratic leaders struck a sober note. Mr. Crowley said that while Democrats could be inclined to sit back and let Mr. Trump be hoisted with his own petard, ''people's lives are at stake.''
''Look, if he's had a road-to-Damascus experience, an epiphany, knocked from his horse and seeing a bright light -- I'm not so sure I'll believe it yet, but maybe it's a start,'' Mr. Crowley said. ''We'll see.''
URL: http://www.nytimes.com/2017/02/12/us/politics/democrats-relish-shifting-responsibility.html
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The New York Times
April 19, 2014 Saturday
Late Edition - Final
Health Care Spending's Recent Surge Stirs Unease
BYLINE: By ANNIE LOWREY
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1
LENGTH: 1101 words
WASHINGTON -- It's back.
For years, because of structural changes in the health care delivery system and the deep economic downturn, the health care ''cost curve'' -- as economists and policy makers call it -- had bent. Health spending was growing no faster than spending on other goods or services, an anomaly in 50 years of government accounts.
But perhaps no longer. A surge of insurance enrollment related to rising employment and President Obama's health care law has likely meant a surge of spending on health care, leaving policy experts wondering whether the government and private businesses can control spending as the economy gets stronger and millions more Americans gain coverage.
''Following several years of decline, 2013 was striking for the increased use by patients of all parts of the U.S. health care system,'' Murray Aitken, executive director of the IMS Institute for Healthcare Informatics, said in a statement.
The news comes as President Obama promotes the success of the Affordable Care Act in covering more Americans at less cost than anticipated.
''Under this law, real Medicare costs per person have nearly stopped growing,'' Mr. Obama said at a news conference on Thursday as he announced that eight million people had signed up for insurance coverage through the law's exchanges.
''Those savings add up to more money that families can spend at businesses, more money that businesses can spend hiring new workers,'' he said, adding that the government's budget scorekeeper ''now says that the Affordable Care Act will be cheaper than recently projected.''
But some health care experts and economists said that an expanded use of the health system might start to have the opposite effect. Americans feeling more economically confident might demand more procedures from doctors and hospitals. Insurers paying more money for those procedures might, in time, increase premiums, cutting into wage gains. The government might end up spending more on the health law than current projections imply.
''We knew this was coming,'' said Douglas Holtz-Eakin, a former head of the Congressional Budget Office and a prominent Republican economist, of rising spending because of the coverage expansion and improving economy. ''The question now is whether we can hold spending down.''
Many other analysts said they had long expected health spending to increase. ''If we are seeing an uptick, it's the beginning of the uptick,'' said Drew Altman, the president of the Henry J. Kaiser Family Foundation. ''We've expected to see a lagged effect, both when the economy declines and when it improves.''
The question is whether health spending might grow moderately, with a one-time bump from new Affordable Care Act enrollees, or whether it might surge, with potentially damaging consequences for the fiscal deficit and wages. Economists from both the right and left -- including in the White House -- have said that there is no greater threat to the government's budget than soaring health spending.
Rising insurance premiums would increase the cost of the health law's expansion. More broadly, experts have warned that the excess growth of health costs could increase the country's debt and crowd out spending on all other priorities, including education, infrastructure, research and development and support for low-income families.
The pace of health spending growth started falling in the mid-2000s and reached historical lows over the last five years. The recession counts for much or even most of the decline, economists think, as workers lost their jobs and their health coverage, and budget-conscious families chose to reduce their out-of-pocket spending.
But at the same time, structural changes to how health care gets delivered and paid for -- changes made by the government, insurers, doctors and hospitals -- also helped hold spending down. Many insurers, for example, began charging much higher co-pays and deductibles, spurring their enrollees to use less care.
Now, health experts said, two big trends are pushing health spending back up again. ''Expanded coverage is happening simultaneously with the petering out of the recession's dampening effect,'' said Charles Roehrig, the director of the Center for Sustainable Health Spending at the Altarum Institute. ''It's going to be hard to demonstrate how much is due to expanded coverage, versus just the economy recovering.''
The data remains preliminary and has not yet provided a clear picture of why health spending is climbing -- let alone how much it might climb, analysts warned. ''We have a handful of data points,'' said David Cutler, a Harvard professor and former economic adviser to Mr. Obama. ''You want a couple hundred, and we just don't have them -- we can't delve deeper yet.''
Even so, all early reports point in the same direction: more money for health care. A report from IMS, a health care data and analytics firm, found use of the health care system increasing broadly in 2013. Americans made more visits to doctors' offices, were hospitalized more often and purchased more prescription medication.
A separate report from the Altarum Institute, a nonprofit research group, also shows that health spending started to climb last summer. This February, spending growth reached a seven-year high.
Government data seem to paint a similar picture, with the annual pace of spending growth on health care increasing to 5.6 percent in the fourth quarter of 2013, from 1.3 percent in the first quarter. That 5.6 percent growth rate is the highest since 2004.
Cognizant of the need to keep health spending per enrollee down, Democratic policy makers included a number of provisions in the health care law to encourage insurers to move away from fee-for-service medicine and to stamp out unnecessary costs. But critics -- and even many supporters -- of the law have repeatedly said it might not be enough.
''This is a criticism I've had of the A.C.A. going back years -- this is not revisionist history,'' Mr. Holtz-Eakin said. ''I thought it was too heavy on the insurance expansion and too light on delivery-system reform. It has tons of projects and demonstrations. But the road to hell is paved with projects and demonstrations.''
Jason Furman, the chairman of the White House's Council of Economic Advisers, cautioned against reading too much into a small number of reports, pointing to a wealth of other data showing that premiums and the price growth of medical goods and services remained low.
''Even if only one-third of the slowdown is sustained,'' he said, ''we will be spending $1,200 less per person on health care after a decade.''
URL: http://www.nytimes.com/2014/04/19/business/economy/health-care-spendings-recent-surge-stirs-unease.html
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The New York Times Blogs
(Fiscal Crisis)
October 2, 2013 Wednesday
Shutdown Provides Material for Late Night
BYLINE: Bill Carter
SECTION: US; politics
LENGTH: 665 words
HIGHLIGHT: While few people may be laughing on Capitol Hill, the government shutdown is irresistible fodder for late-night comedy. The subject has been at the top of every monologue, and the inspiration for several much-viewed comedy bits.
While few people may be laughing on Capitol Hill, the government shutdown is irresistible fodder for late-night comedy. The subject has been at the top of every monologue, and the inspiration for several much-viewed comedy bits.
As might be expected, Jon Stewart has made the shutdown the focus of his political satire on "The Daily Show" with two nights of special themes. The first night, Monday, featured "Rockin' Shutdown Eve," with Mr. Stewart mocking the countdown clocks on every news network and then taking aim at Republicans for apparently not knowing how a bill becomes a law, and for using a form of blackmail to achieve an outcome that they could not through normal means. He joked: "Did you see the Giants game on Sunday? O.K.: they lost 31 to 7. And you know what the Giants didn't say after that game? 'If you don't give us 25 more points by midnight on Monday, we are gonna shut down the N.F.L.' "
On Tuesday, Mr. Stewart changed the theme to the "March of Dumbs," and mocked hyperbolic claims about the threat of the Affordable Care Act. He included a clip of Representative Todd Rokita, Republican of Indiana, calling the law "one of the most insidious laws ever created by man."
Mr. Stewart said that meant it not only surpassed such egregious American historic legal efforts as slavery and Jim Crow, but also worldwide outrages like "the Nuremberg Laws, the Spanish Inquisition and prima nocta, the medieval law where on your wedding night the king gets to sleep with your wife."
His colleague on Comedy Central, Stephen Colbert, had his own "Rockin' Government Shutdown Eve." He played off a famous clip of Ronald Reagan saying that the nine most terrifying words were: "I'm from the government and I'm here to help." The new most terrifying words, Mr. Colbert said, are: "I'm from the government and I will work for food."
On ABC, Jimmy Kimmel included a man-in-the-street interview segment in which people were asked if they liked "Obamacare" or the Affordable Care Act and, predictably, people invariably spoke ill of the first and supported the latter, unaware they are the same thing.
Mr. Kimmel also had numerous monologue jokes about the shutdown, including: "Meanwhile - the Affordable Care Act, also known as
'Obamacare,' which is what everyone is fighting over, became available today. Which is good news for the doctor in your family who has to look at everyone's moles at Thanksgiving."
On NBC, Jay Leno generally went with "pox on both sides" jokes, as he usually does. But he also connected to other recent news topics: "I'm
glad the government has shut down. Think about it, for the first time in years it's safe to talk on the phone and send e-mails without anybody
listening in."
David Letterman on CBS described the shutdown in terms of the entire country being eliminated.
"United States, I don't know what to tell you, not working - call around, see if I'm not right. Nothing's going on. Put up the out-of-business sign.
I mean, we are like a Carnival Cruise on land."
Conan O'Brien, on his late-night show on TBS, delivered several jokes (not printable here) about how far he could now go because the F.C.C. was shut down. He also said: "The federal government has shut down and 800,000 federal employees are out of work. Which explains why tonight our entire studio audience is made up of park rangers and astronauts."
Jimmy Fallon, who follows Mr. Leno on NBC, took note that several reporters smelled alcohol coming from the rooms where Republicans were
meeting to plot their strategy to shut down the government. He said: "There are reports that several members of Congress were actually drinking last night while they were debating the bill that could have avoided the government shutdown. See, Congress is just like most Americans - you know, cause they need to get drunk before they screw people."
And Craig Ferguson on CBS, recalled the last shutdown 17 years ago and said the country could not have endured that back then "if it wasn't for the Macarena."
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September 24, 2016 Saturday
Health Care Deserves More Attention on the Campaign Trail
BYLINE: THE EDITORIAL BOARD
SECTION: OPINION
LENGTH: 772 words
HIGHLIGHT: Why hasn't the growing burden of medical expenses gotten more attention from the presidential candidates?
The reaction to opening a medical bill these days is often shock and confusion - for the insured and the uninsured. Prices and deductibles keep rising, policies are drowning in fine print, and doctors are jumping on and off networks. So why hasn't the growing burden of health care gotten more attention in the presidential campaign?
One reason may be the sheer complexity of the system. Yet Hillary Clinton, if you look closer at her proposals, has a range of interesting ideas on how to tackle costs and improve care. Donald Trump, meanwhile, rarely ventures beyond his "end Obamacare" slogan.
With incomes for most Americans stagnant, individuals and families insured under the Affordable Care Act or through employers are bearing more of the cost of medical treatment.
Deductibles for individual coverage increased 63 percent on average, to $1,221 per year, from 2011 to 2016 for people who get health insurance through their employers, according to a report released last week by the Kaiser Family Foundation and the Health Research and Educational Trust. Workers' contributions to premiums grew more slowly than in previous five-year periods but still jumped 23percent, to $1,129 a year. By contrast, average incomes were up just 11 percent, which means many people are being forced to cut back elsewhere to pay for care. And some people are choosing to forgo or delay going to doctors and hospitals when they are sick.
The cost of prescription drugs is another big problem for people with or without coverage. The average price of brand-name medicines jumped 164 percent from 2008 to 2015, according to Express Scripts. And 24 percent of Americans find it very or somewhat difficult to afford prescription drugs, according to a 2015 Kaiser Family Foundation survey.
Mr. Trump seems oblivious to these trends. His sparse health care proposal is built around a repeal of the Affordable Care Act, without any regard for the millions of people who would be hurt by that change. Twenty million Americans have gained health care coverage in the six years since the law was passed, bringing the uninsured rate to a record low. The law has problems - for example, there are too few insurers offering coverage on the health exchanges in rural and suburban areas - that the next president and Congress will need to fix. But it is generally working effectively and has cost the government less than expected, according to the Congressional Budget Office and the staff of the Joint Committee on Taxation.
Mr. Trump says he would replace the law's subsidies and Medicaid expansion with tax deductions for health insurance premiums paid by individuals and families. But that would primarily benefit the rich, not the millions of low-income and middle-class people who would lose coverage if the law were dismantled. Mr. Trump's plan also includes several vague ideas for lowering costs. One of them is to increase competition among pharmaceutical companies, but Mr. Trump does not say how he would do that.
Mrs. Clinton clearly understands the issues and has some plans that could help. Deductibles and other out-of-pocket costs have risen for workers covered by employer-based plans as businesses have shifted more costs onto employees. Mrs. Clinton wants to provide a tax credit of up to $5,000 to help people pay out-of-pocket costs, including for prescription drugs. That's a good idea, but it would be even better if people received assistance when they faced expenses rather than when they filed their tax returns.
Another proposal from Mrs. Clinton would lower prescription drug costs by allowing Medicare to negotiate with pharmaceutical companies. Drug makers, of course, hate this idea because it would reduce their revenue, and they would surely lobby Congress to defeat a bill. She has also suggested ways to lower costs by hastening the arrival of generic medicines. And she has promised to provide detailed policies to reduce needless medical procedures and to root out fraud and inefficiencies, moves that could prove effective in the longer run.
Health care is just the kind of difficult subject that presidential candidates ought to talk about more. If Mrs. Clinton were to speak regularly and in more detail about her health ideas, she could start building support for them with lawmakers and the public. She would also further expose the shallowness of Mr. Trump's agenda.
This is part of a series about issues that deserve more attention in the presidential campaign.
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September 30, 2013 Monday
A Scramble as Day 1 Approaches
BYLINE: Katie Thomas
SECTION: US
LENGTH: 318 words
HIGHLIGHT: With fewer than 24 hours to go, officials are still working to prepare and explain the new health insurance exchanges scheduled to open on Tuesday.
With fewer than 24 hours until the new health insurance exchanges are scheduled to open, even some of the states that have prepared the most are describing Tuesday as a "soft launch" and warning of technical glitches and other delays, The Times's Abby Goodnough reported Monday.
And given the response to Tara Siegel Bernard's Your Money column over the weekend, confusion over the provisions of the law and how the exchanges will work is mounting as millions of consumers begin to focus on the changes for the first time.
In many ways, the success or failure of the health care law will come down to the very personal decisions of millions of Americans who are in the market for new health insurance. An article by Reed Abelson and me on Sunday told the stories of several of those people, from a young documentary filmmaker in Kentucky who is uninsured to a man in Texas who is struggling to pay mounting medical bills as his wife battles cancer.
Also on Sunday, Ms. Abelson detailed how, five years after President George W. Bush signed a law requiring large employer-based health insurance plans to cover mental illnesses the same way that they cover other diseases, there is widespread agreement that the law has fallen short of its goals.
Robert Pear reported that the Obama administration planned to unveil new options for people planning to sign up for insurance in the marketplaces scheduled to open on Tuesday. These are the plans, known as multistate plans, that were conceived as an alternative to the "public option" championed by liberal Democrats (and opposed by Republicans). They are intended to offer more options in states with little competition.
Polls in Overtime on Affordable Care Act
Answers to Some Questions About Health Care Exchanges
Picking a Plan and a Cobra Choice
Online Map Helps New Yorkers Understand Federal Health Law Benefits
One State's Way to Bolster Health Coverage for Poor
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The New York Times
June 21, 2013 Friday
Late Edition - Final
Weiner Wants City to Test Single-Payer Health Care
BYLINE: By NINA BERNSTEIN
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 19
LENGTH: 820 words
Vowing to ''make New York City the single-payer laboratory in the country'' if he is elected mayor, Anthony D. Weiner on Thursday presented an ambitious plan to create a Medicare-like system for the coverage of municipal workers, retirees and uninsured immigrant residents left out of the Affordable Care Act.
Mr. Weiner, a Democrat who championed a Medicare-for-all style of health care as a congressman, said his plan could curb the rise of $15.5 billion in city spending on health care and save money for raises for teachers and other workers, mainly by using the city's muscle to reduce the profits or the role of private insurance companies.
In return, he proposed that 300,000 city workers and 300,000 retirees who now pay nothing toward their insurance premiums should pay 10 percent -- 25 percent if they smoke. An estimated 500,000 undocumented immigrants would also be expected to buy in to the city's insurance coverage, he said, describing it as a more cost-effective way to care for those whose treatment in emergency rooms and city hospitals already falls to taxpayers.
''This isn't about who manages health care; this is about who manages the money in health care,'' Mr. Weiner said, flicking through slides showing that city spending on workers' health benefits was projected to rise by 40 percent from 2014 to 2017 under the current arrangement. Under an entrenched system partly codified in law, he said, a single private insurance company, Emblem, handles 95 percent of the coverage for the city's workers, and a state board approves annual raises in the rates it charges.
Of insurance companies, he said, ''Their job is to take in as much money as they can and pay out as little as they can.'' The complexity and delays of private insurance processing are no accident, he added: ''They make money on the float.''
Depending on the recommendations of a government task force he would create under a deputy mayor of health care innovation, he said, city coverage might still be placed in the hands of a different insurance company under a more competitive scheme, or the city might outsource just the administration to an insurer, as Medicare does while keeping overhead as low as 1.3 percent. A third option he listed would be for the city ''to take the whole thing in-house.''
He said he would reorganize government agencies to seize opportunities presented by the Affordable Care Act, and have his health care innovation task force consider insurance terms that ''keep more of the money in the city,'' like allowing prescriptions to be filled at local pharmacies rather than only by mail order, or using the city's development and investment capability to increase primary care at a hospital facing closure.
''This is not just a conversation you can have around cost,'' he said, citing the nation's experience in the 1990s with an H.M.O. model that no one liked, and calling the quality of health care in New York ''a crown jewel.''
The coverage devised by the task force, which he called Thrive (standing for Taskforce for Healthcare Reform, Innovation and Vitality for Everyone), could eventually be offered to all New Yorkers by being listed on the state insurance exchange required by the Affordable Care Act. Such an experiment could not be tried in places like Cincinnati or St. Paul, he went on, but ''New York is the health care capital of the world,'' with more than 560,000 health care workers, including tens of thousands of doctors and nurses in the city's own employ.
A single-payer model has been a hard sell nationally because of concern that it would reduce individual choice and increase government control over health care. Mr. Weiner would also have to win support from the city's unions, which may demand raises high enough to offset any contributions they would be required to make to their premiums.
His talk, at a public lecture series sponsored by the Common Good, a nonprofit, nonpartisan organization, at a City University of New York branch on West 67th Street, stirred enthusiasm and interest. In the hour before he spoke, word of Mr. Weiner's proposal galvanized other Democratic candidates for mayor to issue hurried news releases on health care.
Christine C. Quinn, the City Council speaker, drew attention to the BigAppleRx prescription drug discount card, established by Council legislation, which she said had saved more than 125,000 New Yorkers a total of $15,546,017 on prescription medications, or an overall savings of 47 percent, since May 2011.
Public Advocate Bill de Blasio cited health care positions from his policy book, which includes a pledge to enroll 600,000 uninsured New Yorkers in plans through the Affordable Care Act and to better protect community hospitals.
Mr. Weiner, asked how his health care plan compared with those of his rivals, said he was unfamiliar with theirs, adding with a grin, ''And when I say unfamiliar, I may mean I don't think they have any.''
URL: http://www.nytimes.com/2013/06/21/nyregion/weiner-wants-city-to-test-single-payer-health-care.html
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February 12, 2016 Friday
Late Edition - Final
Kentucky Ex-Governor Fights Health Care Changes
BYLINE: By RICHARD PÉREZ-PEÑA
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 495 words
The former governor who made Kentucky a national leader in health care expansion under the Affordable Care Act is moving to protect that legacy from his successor, who has set out to dismantle parts of it.
Steven L. Beshear, the former Democratic governor, announced on Thursday the creation of a nonprofit group, Save Kentucky Healthcare, to marshal opposition to changes being made by Gov. Matt Bevin, a Republican who took office in December.
The effort will begin with online advertising and organizing, Mr. Beshear said, but where it goes from there remains unclear. He declined to say how much money would be behind the campaign, or from what sources.
Kentucky, already a test case for the enthusiastic embrace of the Affordable Care Act, now stands to become a test case for attempts to undo it.
A central part of the federal law mandates an online marketplace in each state where people can shop for insurance. If a state refused to build an exchange, as most did, then the federal government created one.
Another major part of the law allowed states to make Medicaid, the government program for those with a low income, available to far more people, with the federal government paying most of the bill. But the law left it up to each state whether to participate, and 20 have declined.
Under Mr. Beshear, Kentucky expanded Medicaid and created an online exchange, Kynect, which experts called one of the best in the country. The state also tied the parts together: When people visit Kynect, if they are eligible for Medicaid, the system enrolls them in that program.
Since the exchanges opened, Kentucky has had the steepest decline of any state in the number of uninsured people, and Medicaid enrollment nearly doubled. About 7 percent of Kentuckians younger than 65 were uninsured last year, well below the national average, about 11 percent.
While surveys show that Kentuckians view the state's programs favorably, they elected Mr. Bevin, an ardent opponent of the Affordable Care Act, in November. He has backed away from an earlier vow to undo the Medicaid expansion. Instead, he says, he will try to negotiate changes with federal officials, to pare costs and the number of people eligible.
''We cannot afford to have 25 to 30 percent of us on Medicaid,'' Mr. Bevin said in an address to the Legislature in late January.
He has taken steps to dismantle Kynect, saying it will be cheaper to let the federal government run the state's exchange. ''It will not affect the health insurance of a single individual,'' he told the Legislature.
But Mr. Beshear and others argue that eliminating Kynect will result in more uninsured people, primarily by making it harder to enroll in Medicaid. And they point to studies concluding that expanded coverage is a boon to the state, not a drain.
''Governor Bevin simply says, 'I don't believe any of this evidence,' '' Mr. Beshear said. ''He says it's unsustainable based upon some right-wing political ideology.''
URL: http://www.nytimes.com/2016/02/12/us/kentucky-steven-beshear-health-insurance.html
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July 10, 2012 Tuesday
Late Edition - Final
Differing Visions of Health Care Reform
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 20
LENGTH: 747 words
To the Editor:
In ''A Choice, Not a Whine'' (column, July 3), David Brooks claims that the Affordable Care Act ''centralizes power.'' Actually, it does the opposite -- it empowers states, giving them flexibility to adjust benefits to the needs of their citizens, and empowers consumers, putting them, rather than insurance companies, in the driver's seat.
I'd encourage Mr. Brooks, rather than cherry-picking numbers from a few studies, to ask the millions of people the law has already helped if they ''detest'' it.
Ask the 105 million Americans who now know their benefits won't run out because the law bans lifetime dollar limits.
Ask the 12.8 million families who will get rebates from insurers this year because the law requires companies to provide real value for their premium dollar.
Ask the more than 90 million people who have received preventive benefits -- like mammograms, colonoscopies and cholesterol screenings -- for free.
Ask the more than 3.1 million young adults who are now covered on their parents' insurance.
Finally, he should talk to the more than 30 million previously uninsured Americans who will have affordable, comprehensive coverage, regardless of pre-existing conditions.
I applaud the Supreme Court's decision to dismiss the politically motivated and legally unsound lawsuits that sought to undo these vital reforms. Now, all of us must move forward and implement this historic law, which has already improved the country's financial and physical health.
TOM HARKIN Washington, July 4, 2012
The writer, a Democratic senator from Iowa, is chairman of the Health, Education, Labor and Pensions Committee.
To the Editor:
David Brooks lists, as James C. Capretta and Robert E. Moffit's second basic Republican principle for a health care plan: ''Americans should be strongly encouraged to buy continuous coverage over their adulthood.'' But he doesn't say what form the encouragement would take.
a) Asking nicely?
b) Explaining that buying insurance is good for them and for their fellow Americans?
c) Charging a penalty tax for not buying insurance?
Anyone familiar with human nature would choose ''c.'' And that is what the authors of the Affordable Care Act chose.
I invite Mr. Brooks to admit that the Republicans' second principle is in fact the individual mandate of the Affordable Care Act. I invite the Republicans to do the same.
JULIA RUBIN New York, July 4, 2012
To the Editor:
David Brooks's ''coherent'' Republican plan would be a disaster for Americans.
First, it would replace Medicare and its guaranteed coverage with a private voucher system. Second, it would replace Medicaid, our least costly program per person, with far more expensive private insurance.
Third, its ''continuous coverage'' over adulthood that Americans would be ''strongly encouraged'' to buy would occur in the individual insurance market -- the most expensive insurance available.
Fourth, its tax credit to purchase insurance provides the least help to those in the lowest tax brackets -- the ones who need help the most.
Finally, Mr. Brooks's predictions about the Obama plan are at odds with reality. In Massachusetts, which has had a similar plan for six years, employers have not dropped coverage, 98 percent of residents have health insurance, and costs per person have not risen because of the plan.
DAVID SHACTMAN Newton, Mass., July 3, 2012
The writer is the co-author of ''Power, Politics, and Universal Health Care: The Inside Story of a Century-Long Battle.''
To the Editor:
David Brooks should be commended for describing the Republican health reform plan. Who knew they had one? What he did not mention is the name that many Republicans have for such a plan -- Obamacare.
Of the six elements outlined, four are key parts of the Obama plan -- tax credits for purchasing policies, incentives for adults to maintain coverage, flexibility for state experimentation and budgetary offsets for new health care spending. The other two, reform of Medicare and of Medicaid, were not included in the health reform law because they are the subject of separate policy debates.
After more than two years of bitter opposition, it seems that Republicans do not want to repeal ''Obamacare'' entirely after all. They want to claim credit for creating something that is remarkably similar.
ROBERT I. FIELD Hermance, Switzerland, July 4, 2012
The writer is professor of law at the Earle Mack School of Law and professor of health management and policy at the School of Public Health of Drexel University.
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April 14, 2017 Friday
Late Edition - Final
Health Subsidies Become a Pawn To Force Democrats to Bargain
BYLINE: By ROBERT PEAR; Thomas Kaplan contributed reporting from Hannibal, Mo.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1059 words
WASHINGTON -- In the weeks since President Trump's attempts to replace the Affordable Care Act collapsed, the administration has debated what to do: Try again? Shore up the insurance marketplaces? Or let the whole system collapse?
Mr. Trump has failed to get enough support from his own party, but he hopes to get the Democrats' help by forcing them to the negotiating table with hints about the chaos he could cause.
His bargaining chip is the government subsidies paid to insurance companies so they can reduce deductibles and other out-of-pocket costs for low-income consumers -- seven million people this year.
In an interview with The Wall Street Journal this week, Mr. Trump threatened to withhold the subsidy payments as a way to induce the Democrats to bargain with him.
For now, Democrats are resisting and using his maneuver against him to energize their own party. And they warn that Mr. Trump will be blamed if the insurance markets collapse and people lose coverage next year.
''Republicans are in control of government,'' Senator Claire McCaskill, Democrat of Missouri, said Thursday after a town-hall-style meeting in her home state. ''If they blow up what access to health care there is right now, they're going to own it.''
The president's tone differs from that of Republicans in Congress, who have repeatedly promised a smooth transition away from the law they call Obamacare. ''We don't want to pull the rug out from under people,'' the House speaker, Paul D. Ryan, has said.
If the subsidies are interrupted, insurers say, some health plans will increase premiums and others will withdraw from the individual insurance market. That will, in turn, affect millions of other people who do not receive the subsidies.
The issue could come to a head within weeks. When the House reconvenes on April 25, the first order of business will be a spending bill to replace the current stopgap law, which expires three days later. Democrats are determined to put money for the health insurance subsidies into that bill, and some Republicans on the House and Senate Appropriations Committees are open to the idea. But ultimately, the decision will be made by Republican leaders in the two chambers.
If the spending is allowed to continue, the Congressional Budget Office estimates that the federal government will pay $135 billion in cost-sharing subsidies to insurers from 2018 to 2027.
The cloud of uncertainty swirling around the subsidies stems from a court ruling in a lawsuit that House Republicans filed against the Obama administration in 2014. Judge Rosemary M. Collyer of the Federal District Court in Washington ruled last year that spending on the subsidies ''violates the Constitution'' because Congress never appropriated money for them. She ordered a halt to the payments, but suspended her order to allow the government to appeal.
The Trump administration has not made clear whether it will press the appeal filed by the Obama administration. In a letter to Mr. Trump this week, the U.S. Chamber of Commerce joined the American Medical Association, the American Hospital Association and insurers in seeking ''quick action'' to guarantee continuation of the subsidies. Without the subsidies, they said, more people will be uninsured and unable to pay medical bills.
Democrats say they will not negotiate with Mr. Trump until he stops his drive to repeal the Affordable Care Act. ''President Trump is threatening to hold hostage health care for millions of Americans, many of whom voted for him, to achieve a political goal of repeal that would take health care away from millions more,'' said the Senate Democratic leader, Chuck Schumer of New York.
Having no immediate prospect of a deal with Democrats, the White House is still focusing on Republicans. It is seeking consensus on a repeal bill that can overcome rifts among House Republicans, whose disagreements sank an earlier version of the legislation on March 24.
Even though lawmakers are out of town for a two-week spring break, Mr. Trump and Vice President Mike Pence are continuing efforts to revive the bill in talks with Representative Mark Meadows, the North Carolina Republican who is the chairman of the conservative House Freedom Caucus.
Many conservatives opposed the earlier version of the bill, saying it did not do enough to repeal federal rules that drive up the cost of insurance. Democrats say those rules, including a definition of minimum benefits, provide essential protections for consumers.
Asked about the outlook for a deal, Sean Spicer, the White House press secretary, said Tuesday, ''I think we're getting closer and closer every day.'' But potential gains among conservatives risk alienating moderate Republicans.
Representative Justin Amash, Republican of Michigan and a member of the Freedom Caucus, said at a town hall-style meeting this week that 50 to 80 Republicans would have voted against the bill that was pulled from the House floor last month.
Mr. Amash had a suggestion for the administration and House leaders. ''Let's start over in a bipartisan way,'' he said. ''We should have worked with Democrats from the very beginning. At the end of the day, you cannot pass legislation, whether it's the A.C.A. or a new health care proposal, that affects so many people and not have it be bipartisan.''
The Trump administration announced rule changes on Thursday that it said would help stabilize insurance markets and reduce premiums. The new rules would cut the annual open enrollment period in half, so it would run from Nov. 1 through Dec. 15 this year. If consumers wanted to sign up at other times, they would have to submit documents to prove they were eligible for a ''special enrollment period.''
Marilyn B. Tavenner, the chief executive of America's Health Insurance Plans, a lobby for insurers, welcomed the changes but said they were not enough.
''Most urgently,'' she said, ''health plans and the consumers they serve need to know that funding for cost-sharing reduction subsidies will continue uninterrupted. Without funding, millions of Americans who buy their own plan will be harmed. Many plans will likely drop out of the market. Premiums will go up sharply -- nearly 20 percent -- across the market.''
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URL: https://www.nytimes.com/2017/04/13/us/politics/health-care-affordable-care-act-trump.html
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January 4, 2017 Wednesday
Late Edition - Final
Amid Chaos, G.O.P. Presses On With Effort to Repeal Health Law
BYLINE: By JENNIFER STEINHAUER and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1345 words
WASHINGTON -- The Republican-controlled Congress opened the turbulent Trump era in Washington on Tuesday, as the new Senate moved instantly to begin the repeal of President Obama's signature health care law while the House descended into chaos in an ill-fated attempt to gut an independent congressional ethics office.
On a day usually reserved for pomp, constitutionally mandated procedure and small children parading around in fancy dresses, Congress instead pitched itself into partisan battles.
Speaker Paul D. Ryan easily won re-election, but not before the embarrassment of having his members defy him by voting to eliminate the ethics office, only to then abandon that effort after a flood of criticism from constituents and Twitter messages from President-elect Donald J. Trump that criticized House Republican priorities.
It was a rocky start to a period in which Republicans had promised an end to Washington gridlock if they controlled both Congress and the White House. There was intraparty conflict and a sense that Mr. Trump, who ran against the Republican establishment, would continue to be openly critical of his own party at times.
As Democrats in both chambers seethed, Senator Mitch McConnell of Kentucky, the majority leader, unveiled the legislative language that could decimate the Affordable Care Act before the crocuses start to bloom in the spring, even if any replacement of the law could take years.
Budget language released on Tuesday gives House and Senate committees only until Jan. 27 to produce legislation that would eliminate major parts of the health care law. Under arcane budget procedures, that legislation would be protected from a Democratic filibuster and could pass the Senate with a simple majority. And debate will begin on Wednesday, before senators have even moved into their new offices.
The dueling over the health law's fate will pull in both the departing and incoming White House administrations as well. On Wednesday, Mr. Obama will visit with congressional Democrats to plot how to resist the planned repeal, and Mike Pence, the vice president-elect, will meet with Republicans to gird them for the fight ahead.
While the Senate action showed Republicans on course to keep campaign promises, the House got off to a messy start, brought on by Republicans who had moved largely in secret on Monday to gut a congressional ethics office against Mr. Ryan's wishes.
That provoked an outcry from both Democrats and voters who flooded House offices with angry calls. ''Every left-wing organization is calling my office,'' said Representative Pete Sessions, Republican of Texas. ''And we've told them: 'Thank you very much. We appreciate your feedback.'''
After a hastily called meeting on Tuesday morning among Republicans, the matter was dropped before it could go to the full House floor for a vote.
As the Senate moved to larger legislative matters, the House kerfuffle seemed to cast a shadow over Mr. Ryan, but he tried to brush it off. ''There's no sense of foreboding in the House today,'' Mr. Ryan said after his re-election, ''only the sense of potential.''
The fight over the House rules was already acrimonious thanks to a piece of the package that would impose $2,500 in fines for filming events on the House floor, a response to Democrats who streamed their overnight sit-in over guns last June using cellphones and video cameras.
In the Senate, Vice President Joseph R. Biden Jr. swore in seven new members and all the incumbents who won their races last year, their colleagues looking on cheerfully, as a cold rain pelted the newly refurbished Capitol dome.
Members of the House and Senate brought along their families -- elderly parents with canes, small children tugging at uncomfortable lacy hems -- as well as former senators and other special guests. Former Vice President Dick Cheney accompanied his daughter Liz to her swearing-in as a member of the House elected from Wyoming.
Senator Chuck Schumer of New York officially became the Democratic leader and quickly warned Republicans that the minority would be vocal, if not operatic, in resisting much of their agenda and many of Mr. Trump's nominees.
''It is our job to do what's best for the American people, the middle class and those struggling to get there,'' he said. ''If the president-elect proposes legislation on issues like infrastructure, trade and closing the carried interest loophole, for instance, we will work in good faith to perfect and, potentially, enact it. When he doesn't, we will resist.''
He added, ''If President-elect Trump lets the hard-right members of Congress and his cabinet run the show, if he adopts their timeworn policies -- which benefit the elites, the special interests and corporate America, not the working man and woman -- his presidency will not succeed.''
On Tuesday, the House also adopted rules clearing the way for legislation to roll back the health care law.
The budget blueprint introduced on Tuesday in the Senate is not sent to the president and does not become law, but still clears the way for subsequent legislation that Republicans say will repeal major provisions of the Affordable Care Act.
Republicans bypassed the Budget Committee so they could immediately bring the measure to the floor. Such resolutions are normally developed after weeks of work in the Budget Committee.
Under the plan, four congressional committees -- two in the House and two in the Senate -- have until Jan. 27 to develop legislation that will be the vehicle for repealing the health care law.
The document does not specify which provisions of the law may be eliminated and which ones may be preserved. Nor does it specify or even suggest how Republicans would replace the Affordable Care Act, which the Obama administration says has provided coverage to some 20 million people who were previously uninsured.
Republicans have said they may delay the effective date of a repeal bill, to avoid disrupting coverage for people who have it and to provide time for Republicans to develop alternatives to the 2010 health law.
The budget blueprint allows Republicans to use savings from repealing major provisions of that law to help offset the cost of future, unspecified measures to help people obtain coverage.
''Americans face skyrocketing premiums and soaring deductibles,'' said Senator Mike Enzi, Republican of Wyoming and chairman of the Senate Budget Committee. ''Insurers are withdrawing from markets across the country, leaving many families with fewer choices and less access to care than they had before -- the opposite of what the law promised.''
The American Medical Association urged Congress on Tuesday to explain how it would replace the Affordable Care Act. ''Before any action is taken through reconciliation or other means that would potentially alter coverage, policy makers should lay out for the American people, in reasonable detail, what will replace current policies,'' the chief executive of the association, Dr. James L. Madara, said in a letter to congressional leaders.
Representative Nancy Pelosi of California, who engineered the House passage of the health law in 2010, promised this week that Democrats would be just as aggressive in fighting its repeal.
Republicans have said they may delay legislation to replace the health law for several years. Ms. Pelosi said that such a delay would be ''an act of cowardice on the part of Republicans,'' and that ''they don't even have the votes to do it'' because they have not agreed on a replacement plan.
Democrats also vowed to give Mr. Trump's cabinet nominees rigorous scrutiny.
Senator Dianne Feinstein of California, the highest-ranking Democrat on the Judiciary Committee, has written to Senator Charles E. Grassley of Iowa, the committee chairman, asking to postpone the first scheduled confirmation hearing, set for next week for Senator Jeff Sessions of Alabama, whom Mr. Trump has chosen as attorney general.
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URL: http://www.nytimes.com/2017/01/03/us/politics/congress-biden-ryan.html
LOAD-DATE: January 4, 2017
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: Paul D. Ryan, who easily won re-election as House speaker, swore in members of the 115th Congress on Tuesday. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES)
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The New York Times
January 9, 2016 Saturday
Late Edition - Final
As Expected, Obama Vetoes Repeal of Health Law
BYLINE: By GARDINER HARRIS
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 589 words
WASHINGTON -- President Obama vetoed legislation Friday that would have repealed the Affordable Care Act and stripped all federal funds from Planned Parenthood, writing in his veto message that the measure would ''reverse the significant progress we have made in improving health care in America.''
Mr. Obama's veto -- only the eighth of his presidency -- was expected, and his decision to issue a simple message without holding a public ceremony indicated that he did not wish to draw attention to the showdown. Republicans do not have the votes in the House or the Senate to override the veto.
But it shows that nearly six years after its enactment, the health law remains one of the most divisive political issues of the Obama presidency. For many Americans, the health law is seen as costly, cumbersome and a government infringement on freedoms, even as it has spread health coverage to millions and ensured popular benefits like ending lifetime coverage limits and the denial of insurance for pre-existing medical conditions. This week's House vote was the 62nd to fully or partly repeal the health law but only the first that sent legislation to the president's desk.
The White House has long expected that the fierce politicking around the law would wane as millions of people got coverage and other issues took center stage. But while some Republican governors have decided to take advantage of the law's provisions to expand Medicaid coverage in their states, Republican legislators in Congress remain persuaded that the law is collapsing and are determined to help it fail. Republicans also showed they could use arcane budgetary rules to circumvent a Democratic filibuster and pass repeal legislation for the signature of a Republican president.
''We have now shown that there is a clear path to repealing Obamacare without 60 votes in the Senate,'' House Speaker Paul D. Ryan of Wisconsin said after the veto. ''So, next year, if we're sending this bill to a Republican president, it will get signed into law. Obamacare will be gone.''
In recent months, insurers have increased premiums and deductibles for many policies sold on the law's online marketplace, and a dozen nonprofit insurance co-ops created by the law have closed their doors after struggling financially.
In his veto message, Mr. Obama noted that under the Affordable Care Act, about 17.6 million Americans had gained health care coverage under the law.
Mr. Obama also objected to provisions in the repeal legislation to defund Planned Parenthood, a women's health organization that also provides abortions. While noting that federal law already prohibits funding for nearly all abortions, Mr. Obama said that eliminating funding for an organization that is a major provider of health care in the nation would ''disproportionately impact low-income individuals.''
Finally, Mr. Obama noted that Republicans in Congress have sought to repeal the health care law more than 50 times.
''Rather than fighting old political battles by once again voting to repeal basic protections that provide security for the middle class, members of Congress should be working together to grow the economy, strengthen middle-class families and create new jobs,'' Mr. Obama wrote.
He then concluded, ''Because of the harm this bill would cause to the health and financial security of millions of Americans, it has earned my veto.''
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URL: http://www.nytimes.com/2016/01/09/us/politics/obama-vetoes-bill-to-repeal-health-law-and-end-planned-parenthood-funding.html
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The New York Times
October 24, 2015 Saturday
Late Edition - Final
House Republicans' Budget Bill Deepens Rift as U.S. Debt Deadline Nears
BYLINE: By DAVID M. HERSZENHORN
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 914 words
WASHINGTON -- House Republicans on Friday adopted a budget reconciliation package that would repeal core components of the Affordable Care Act and cut off government funding of Planned Parenthood. The move drew criticism from Democrats, who said the measure was wasting valuable time because it has no chance of becoming law and comes just days before the government will default on its debt unless Congress takes action.
While the reconciliation package can be adopted in the Republican-controlled Senate with a simple majority -- circumventing the usual procedural obstacles -- it faces certain veto by President Obama.
In that sense, Friday's vote -- by Democrats' count, it was the 61st attempt to repeal all or part of the health care law -- showed Republican lawmakers still angrily throwing air punches at the president even as Representative Paul D. Ryan of Wisconsin is set to become speaker next week, hoping to usher in a more productive era in the House.
A few Republicans, including three senators, even criticized the bill, saying that it did not go far enough and should have fully repealed the health care law, Mr. Obama's signature domestic policy achievement. In the House, the vote was 240 to 189, mostly following party lines, but with seven Republicans opposed and one Democrat in favor.
''This reconciliation package, getting it to the president's desk, is a real, real positive step in ending government-controlled health care in this country,'' Representative Todd Rokita, Republican of Indiana, said in a speech on the House floor.
Democrats rejected that view, noting Mr. Obama's inevitable veto. And they cited Thursday's marathon hearing, at which Republicans grilled Hillary Rodham Clinton about the 2012 attack in Benghazi, Libya, as further evidence of a Republican House that they said was focused more on political messages than on governing the country.
''Let's stop the games,'' said Representative Chris Van Hollen of Maryland, the senior Democrat on the Budget Committee. ''We've got to deal with the debt ceiling.''
He added, ''We've got to come together to prevent a government shutdown.''
The Treasury Department has said that the government will run out of money to pay its bills on Nov. 3 unless Congress acts to raise the debt ceiling. Many House Republicans are fiercely opposed to doing so, unless there is accompanying legislation that overhauls mandatory spending programs like Social Security, Medicare and Medicaid.
The exiting speaker, John A. Boehner, is hoping to deal with the debt-ceiling issue before handing the gavel over later next week. To do so, however, he will need to find 35 to 40 Republicans who are willing to join Democrats in raising the debt ceiling without condition, as Mr. Obama has demanded.
On Thursday, House Republican leaders decided not to bring a measure to the floor that would have imposed an array of conditions on lifting the debt ceiling after they concluded that there was not sufficient consensus among Republicans to adopt it.
Beyond the need to raise the debt ceiling, major infrastructure programs expire at the end of the month and require reauthorization, while a temporary spending measure that prevented a government shutdown earlier this month is set to run out on Dec. 11.
On Monday, there is also expected to be a highly contentious debate in the House over reauthorizing the Export-Import Bank, following a rare procedural step in which rank-and-file Republicans and Democrats joined to force House leaders to call a vote on the matter.
That small show of bipartisanship was a brief exception to the rancor that characterizes most business in Congress these days. Those divisions were on full display during Friday's floor debate over the reconciliation package, as Republicans cheered the push to repeal the Affordable Care Act.
''This is a great opportunity to get some awful things off the back of the American public,'' said Representative Peter Roskam, Republican of Illinois.
Many Republicans have been angered by videos that purport to show Planned Parenthood officials discussing the sale of aborted fetuses for use in medical research. Planned Parenthood has said that opponents of abortion rights doctored those videos.
House Republicans have undertaken several investigations, and at one point were pressing to include provisions in the temporary spending measure that would have cut funding for Planned Parenthood. Those efforts failed, and Democrats said the push on the reconciliation would have a similar result.
House Democratic leaders on Friday held a news conference in which they called on Republicans to swiftly move a measure that lifts the debt ceiling without conditions.
''We have seven legislative days left until we default on the full faith and credit of the United States of America,'' said the Democratic leader, Nancy Pelosi of California. ''This is a very, very serious matter -- in fact, it's as serious as it gets for our economy, for interest rates.''
Even as the Democrats were talking about the debt limit, Republicans were lining up to take ceremonial photographs with Mr. Boehner, a sign of the historic shift that will take place next week. In an initial vote on Wednesday, Republicans are expected to nominate Mr. Ryan to be speaker, with a formal vote on the House floor set for Thursday.
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URL: http://www.nytimes.com/2015/10/24/us/politics/house-republicans-embrace-budget-bill-ahead-of-debt-deadline.html
LOAD-DATE: October 25, 2015
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: Representative Paul D. Ryan, who is poised to become the next House speaker, leaving his office on Capitol Hill on Friday. (PHOTOGRAPH BY ZACH GIBSON/THE NEW YORK TIMES)
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The New York Times
March 6, 2017 Monday
Late Edition - Final
A Party Not Ready to Govern
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 23
LENGTH: 846 words
According to Politico, a Trump confidante says that the man in the Oval Office -- or more often at Mar-a-Lago -- is ''tired of everyone thinking his presidency is screwed up.'' Pro tip: The best way to combat perceptions that you're screwing up is, you know, to stop screwing up.
But he can't, of course. And it's not just a personal problem.
It goes without saying that Donald Trump is the least qualified individual, temperamentally or intellectually, ever installed in the White House. As he veers from wild accusations against President Obama to snide remarks about Arnold Schwarzenegger, he's doing a very good imitation of someone experiencing a personal breakdown -- even though he has yet to confront a crisis not of his own making. Thanks, Comey.
But the broader Republican quagmire -- the party's failure so far to make significant progress toward any of its policy promises -- isn't just about Mr. Trump's inadequacies. The whole party, it turns out, has been faking it for years. Its leaders' rhetoric was empty; they have no idea how to turn their slogans into actual legislation, because they've never bothered to understand how anything important works.
Take the two lead items in the congressional G.O.P.'s agenda: undoing the Affordable Care Act and reforming corporate taxes. In each case Republicans seem utterly shocked to find themselves facing reality.
The story of Obamacare repeal would be funny if the health care -- and, in many cases, the lives -- of millions of Americans weren't at stake.
First we had seven -- seven! -- years during which Republicans kept promising to offer an alternative to Obamacare any day now, but never did. Then came the months after the election, with more promises of details just around the corner.
Now there's apparently a plan hidden somewhere in the Capitol basement. Why the secrecy? Because the Republicans have belatedly discovered what some of us tried to tell them all along: The only way to maintain coverage for the 20 million people who gained insurance thanks to Obamacare is with a plan that, surprise, looks a lot like Obamacare.
Sure enough, the new plan reportedly does look like a sort of half-baked version of the Affordable Care Act. Politically, it seems to embody the worst of both worlds: It's enough like Obamacare to infuriate hard-line conservatives, but it weakens key aspects of the law enough to deprive millions of Americans -- many of them white working-class voters who backed Donald Trump -- of essential health care.
The idea, apparently, is to deal with these problems by passing the plan before anyone gets a chance to really see or think about what's in it. Good luck with that.
Then there's corporate tax reform -- an issue where the plan being advanced by Paul Ryan, the House speaker, is actually not too bad, at least in principle. Even some Democratic-leaning economists support a shift to a ''destination-based cash flow tax,'' which is best thought of as a sales tax plus a payroll subsidy. (Trust me.)
But Mr. Ryan has failed spectacularly to make his case either to colleagues or to powerful interest groups. Why? As best I can tell, it's because he himself doesn't understand the point of the reform.
The case for the cash flow tax is quite technical; among other things, it would remove the incentives the current tax system creates for corporations to load up on debt and to engage in certain kinds of tax avoidance. But that's not the kind of thing Republicans talk about -- if anything, they're in favor of tax avoidance, hence the Trump proposal to slash funding for the I.R.S.
No, in G.O.P. world, tax ideas always have to be presented as ways to remove the shackles from oppressed job creators. So Mr. Ryan has framed his proposal, basically falsely, as a measure to make American industry more competitive, focusing on the ''border tax adjustment'' which is part of the sales-tax component of the reform.
This misrepresentation seems, however, to be backfiring: it sounds like a Trumpist tariff, and has both conservatives and retailers like WalMart up in arms.
At this point, then, major Republican initiatives are bogged down for reasons that have nothing to do with the personality flaws of the tweeter in chief, and everything to do with the broader, more fundamental fecklessness of his party.
Does this mean that nothing substantive will happen on the policy front? Not necessarily. Republicans may decide to ram through a health plan that causes mass suffering, and hope to blame it on Mr. Obama. They may give up on anything resembling a principled tax reform, and just throw a few trillion dollars at rich people instead.
But whatever the eventual outcome, what we're witnessing is what happens when a party that gave up hard thinking in favor of empty sloganeering ends up in charge of actual policy. And it's not a pretty sight.
Read my blog, The Conscience of a Liberal, and follow me on Twitter, @PaulKrugman.
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URL: http://www.nytimes.com/2017/03/06/opinion/a-party-not-ready-to-govern.html
LOAD-DATE: March 6, 2017
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The New York Times Blogs
(The New Old Age)
October 14, 2011 Friday
Administration Nixes the Class Act
BYLINE: THE NEW YORK TIMES
SECTION: HEALTH
LENGTH: 228 words
HIGHLIGHT: The Obama Administration on Friday backed away from what would have been the first government-run insurance program for long-term care.
The Obama Administration on Friday announced that it was scrapping the Class Act, the government-run insurance program for long-term care authorized by the Affordable Care Act, essentially because the numbers could not be made to work. Robert Pear reports:
Premiums for the program . . . would be so high that very few people would sign up, officials said.
The program had a longtime champion in Senator Edward M. Kennedy, Democrat of Massachusetts, before his death from a brain tumor in August 2009 and was seen as a breakthrough in addressing the need for long-term care.
But critics, including some Democrats, said they feared that it was unworkable. Some administration officials shared that concern, but did not speak up when the law was passed in March 2010.
Last month, workers were reassigned from the office that was developing the program, but at the time, Erin Shields, director of communications for health issues at the federal Department of Health and Human Services, said only that the office was being "reduced" and that a study of the program was continuing.
Read the full story, "Obama Administration to Scrap Long-Term Care Insurance Part of Health Care Law," and share your thoughts in the comments section.
More on the Class Act
The Class Act in the Crosshairs
The Curtain Rises on the Class Act
Uncle Sam Wants You (Yes, You)
Details on the Class Act, Pt. 2
LOAD-DATE: October 14, 2011
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PUBLICATION-TYPE: Web Blog
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The New York Times Blogs
(Taking Note)
February 5, 2014 Wednesday
No, 'Obamacare' Isn't Killing 2 Million Jobs
SECTION: OPINION
LENGTH: 294 words
HIGHLIGHT: The C.B.O. director clearly distinguished between getting laid off and choosing not to work.
Opponents of the Affordable Care Act yesterday seized on a Congressional Budget Office report on the labor market, claiming it indicated that health reform would "kill" 2 million jobs. Actually, as our editorial on the subject explained, the C.B.O. report predicted a reduction in the number of full-time workers. That may sound like a distinction without a difference, but it's not. "Job-killing" implies layoffs; whereas the report found that many workers would choose to leave their positions - because they no longer have to depend on their employers for health insurance.
Since there's been so much confusion on this vital point, I thought I'd highlight what Douglas Elmendorf, the C.B.O. budget director, told the House Budget Committee on Wednesday. He clearly distinguished between getting laid off and choosing not to work:
"The reason that we don't use the term 'lost jobs' is because there is a critical difference between people who would like to work and can't find a job - or have a job that was lost for reasons beyond their control - and people who choose not to work. If someone comes up to you and says, 'Well the boss says I'm being laid off because we don't have enough business to pay me,' that person feels bad about that and we sympathize with them for having lost their job. If someone says, 'I decided to retire or stay home and spend more time with my family or spend more time doing my hobby,' they don't feel bad about it - they feel good about it. And we don't sympathize. We say congratulations. And we don't say they've lost their job. We've say they've chosen to leave their job."
What's Behind the Declining Abortion Rate?
Looking Callous at the SOTU
Mike Huckabee's War for Women
Pajama Boy Vs. Duck Dynasty
The Real Health Care Distraction?
LOAD-DATE: February 5, 2014
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The New York Times Blogs
(Taking Note)
November 20, 2013 Wednesday
Talking Health Insurance Over Thanksgiving Dinner
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 276 words
HIGHLIGHT: The president’s urging Americans to “have the talk” this holiday season.
Here's a hypothetical scenario: You're the president. You've just botched the roll out of what should have been your signature accomplishment, a major reform of the health insurance system. The public's hopping mad because you said anyone who liked his insurance plan would be able to keep it, but that wasn't true.
So what do you do now?
What the actual president did was suggest we all discuss health insurance with their families this holiday season.
If you subscribe to the Barack Obama Twitter fee, you got this note yesterday afternoon:
When your loved ones get together this holiday season, remember to talk to them about health insurance. http://t.co/6omO1vDKBj#GetTalking
- Barack Obama (@BarackObama) November 19, 2013
The link leads to a snazzily designed website called "Health Care for the Holidays," which features a "packing list" of the basic information you need to sign up for insurance, and urges everyone to "have the talk" over Thanksgiving.
I can just hear how it might go.
"Uncle Ralph, remember how you drank too much last year, choked on a turkey bone and ran up all those medical bills? Maybe you should check out HealthCare.gov."
"I tried, but the website wouldn't work."
I have been a big supporter, from the start, of the Affordable Care Act. If anything the reform program did not go far enough toward universal coverage.
But I question the wisdom of directing people to a cheery ad for the exchanges before they, you know, work. The president's communications team is just asking for it.
Cutting the Heart Out of Health Reform
Obama's Health Care Promise
Boehner's Last Stand
G.O.P. Helps Americans Like Government
Obama's Message to the Middle
LOAD-DATE: November 20, 2013
LANGUAGE: ENGLISH
DOCUMENT-TYPE: News
PUBLICATION-TYPE: Web Blog
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The New York Times Blogs
(Taking Note)
November 20, 2013 Wednesday
Talking Health Insurance Over Thanksgiving Dinner
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 276 words
HIGHLIGHT: The president’s urging Americans to “have the talk” this holiday season.
Here's a hypothetical scenario: You're the president. You've just botched the roll out of what should have been your signature accomplishment, a major reform of the health insurance system. The public's hopping mad because you said anyone who liked his insurance plan would be able to keep it, but that wasn't true.
So what do you do now?
What the actual president did was suggest we all discuss health insurance with their families this holiday season.
If you subscribe to the Barack Obama Twitter feed, you got this note yesterday afternoon:
When your loved ones get together this holiday season, remember to talk to them about health insurance. http://t.co/6omO1vDKBj#GetTalking
- Barack Obama (@BarackObama) November 19, 2013
The link leads to a snazzily designed website called "Health Care for the Holidays," which features a "packing list" of the basic information you need to sign up for insurance, and urges everyone to "have the talk" over Thanksgiving.
I can just hear how it might go.
"Uncle Ralph, remember how you drank too much last year, choked on a turkey bone and ran up all those medical bills? Maybe you should check out HealthCare.gov."
"I tried, but the website wouldn't work."
I have been a big supporter, from the start, of the Affordable Care Act. If anything the reform program did not go far enough toward universal coverage.
But I question the wisdom of directing people to a cheery ad for the exchanges before they, you know, work. The president's communications team is just asking for it.
Cutting the Heart Out of Health Reform
Obama's Health Care Promise
Boehner's Last Stand
G.O.P. Helps Americans Like Government
Obama's Message to the Middle
LOAD-DATE: November 20, 2013
LANGUAGE: ENGLISH
DOCUMENT-TYPE: News
PUBLICATION-TYPE: Web Blog
Copyright 2013 The News York Times Company
All Rights Reserved
785 of 1000 DOCUMENTS
The New York Times
April 2, 2013 Tuesday
Late Edition - Final
In Washington, Abortion Debate Counters Trend
BYLINE: By KIRK JOHNSON
SECTION: Section A; Column 0; National Desk; Pg. 10
LENGTH: 890 words
OLYMPIA, Wash. -- The legality or availability of abortion is under challenge from North Dakota to Arkansas this spring as conservative state legislatures throw down roadblocks. But here in this corner of the Far West, winds may blow the other way.
Washington already was the only state ever to have legalized abortion through a popular vote -- in 1970, three years before the United States Supreme Court defined the national legal terrain on the issue in Roe v. Wade -- and is now debating a law that would require health insurers to pay for an elective abortion.
It is a lonely conversation, national advocates for abortion choice said.
Conservative hostility to the changes looming under the federal health care overhaul, formally the Affordable Care Act, and a widespread belief that a majority on the Supreme Court might be ready to overturn the Roe v. Wade precedent, the advocates said, have combined to rekindle a brush fire that mostly blazes in one direction. In addition, an influx of Republicans swept into many statehouses starting with midterm elections in 2010.
''States are overwhelmingly ruled by anti-choice politicians,'' said Donna Crane, policy director for the National Abortion Rights Action League, which is based in Washington, D.C. ''The Affordable Care Act has probably added some extra octane to the efforts from our opponents.''
The result, she said, is an ''uptick in bills.''
The bill here, H.B. 1044, also known as the Reproductive Parity Act, passed in the Democrat-controlled State House in February, by a 53-to-43 vote. A backer of the bill in the Senate said Monday at a packed public hearing before the Senate Health Care Committee that 25 senators out of 49 have signed on to vote yes if the measure reaches the floor.
But people on both sides of the question said the crux of the bill came down to choice -- a word intertwined with the language of abortion for many years, now loaded with new shades of meaning about fine-print insurance coverage, mandates and fairness.
Opponents said the bill would require a provision of health insurance coverage -- paying for abortions -- that many people do not want and do not want to be part of, even by doing business with a company that provides it. Supporters said that since the federal health care law allowed insurance carriers to opt out of covering abortion, many might well do so when the law kicks in next January unless the state steps in now with new rules.
The bill was amended in the House to provide for a religious conscience exemption for an employer or insurance carrier that opposes abortion, but opponents said the language was vague and contradictory and would provide no protection, or could lead to expensive lawsuits against those who decide to opt out for religious reasons.
''This is also a bullying bill'' that forces people who oppose abortion to be part of a system that permits abortions, said Angela Connelly, president of the Washington Women's Network, which she described as an advocacy group working on issues including human trafficking and elder abuse. ''We cannot insist on one agenda oppressing another.''
The chief executive officer of Planned Parenthood Votes Northwest, Elaine Rose, said the question was about maintaining access to abortion that Washingtonians have said repeatedly, since 1970, that they want and expect. She said the federal health care law, though passed mostly by Democrats in Congress, could ''complicate'' abortion access in socially liberal Washington State through its rules.
Since the enactment of the Affordable Care Act in March 2010, at least 17 states have enacted legislation to restrict coverage for abortion in their insurance exchanges, according to the National Conference of State Legislatures.
''Today every carrier and nearly every plan in Washington already covers abortion,'' Ms. Rose told the panel of senators. ''The Reproductive Parity Act will keep it that way.''
Politics in Olympia, and especially in the State Senate, are anything but simple this year, making predictions difficult.
Although the Democrats have 26 seats to 23 for the Republicans, the Republican minority was joined in December by two Democrats, creating a bipartisan ruling group. The coalition's majority leader, Senator Rodney Tom, a Democrat, supports abortion rights, but many of the members of the coalition he leads go the other way. That means that if the bill reaches the floor, passage would require a flip side of the leadership coalition -- Democrats leading the yes votes, presumably with Senator Tom back among his old caucus.
Gov. Jay Inslee, a Democrat elected in November, is a strong supporter of the Reproductive Parity Act and has urged the Senate to move forward on it.
In North Dakota, by contrast, the momentum mostly has gone the other way. Gov. Jack Dalrymple, a Republican, signed a bill into law last month prohibiting most abortions after a detectable heartbeat is present -- essentially banning almost any abortion, since a heartbeat can be found even before many women even know they are pregnant. Arkansas's legislature passed a law, over the veto of Gov. Mike Beebe, a Democrat, banning any abortion after 12 weeks.
Monday's hearing, which was restricted to two hours, left dozens of people unable to speak, and some were cut off if they veered from a focus on the bill or went over their time.
URL: http://www.nytimes.com/2013/04/02/us/washington-state-abortion-debate-counters-the-trend.html
LOAD-DATE: April 2, 2013
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: A Reproductive Parity Act opponent in Olympia, Wash.
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The New York Times
November 11, 2013 Monday
Late Edition - Final
High and Low Premiums in Health Care
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 24
LENGTH: 526 words
The debate over the effect the Affordable Care Act will have on individuals and families who buy their own policies has mostly been waged in anecdotes. Supporters of the law point to grateful individuals who were previously unable to get insurance or paid exorbitant premiums but found affordable coverage on the new health insurance exchanges. Critics counter with frustrated people who liked their old policies but will now be forced to buy a more comprehensive policy and pay a higher premium for it.
As it turns out, there are estimates of how many people might fall into one category or the other. Up to seven million people may be able to get health policies without paying any premium at all. Some four million people may have to pay more for new (and better) policies, not all of whom will necessarily be upset at getting better coverage at a competitive rate.
As Reed Abelson and Katie Thomas reported in The Times last week, three independent estimates by Wall Street analysts found that five million to seven million people will qualify for federal subsidies that will exceed the cost of the cheapest plans for individuals and families on the exchanges. Neither the Obama administration nor the insurance companies, however, are promoting the plans vigorously. They believe that many consumers would be better off paying a bit more for a policy that would cover more of the out-of-pocket costs for a doctor's visit or hospital stay.
In the wake of the federal website problems, there's worry about whether the administration can reach its goal of enrolling seven million uninsured Americans in 2014. Surely the five million to seven million eligible for zero-premium policies would be an easy sell. About half of them are under age 39 and uninsured, the kind of young people the exchanges need to broaden the risk pools. Health officials should pull out all the stops to identify and enroll them.
There is no official estimate of how many higher-income earners who have been buying individual policies would pay more when forced to buy new policies. Jonathan Gruber, a health economist at the Massachusetts Institute of Technology who played a role in shaping the Affordable Care Act, estimates 12 million people are currently covered by policies bought on the individual market. He says that, after factoring in subsidies on the exchanges, perhaps eight million will be covered by less costly policies next year, and four million will be covered by more expensive policies, which often provide richer benefits.
Individuals facing higher premiums are understandably distressed. But there is no getting around the fact that health reform changes the status quo -- including requiring insurance companies to provide essential health benefits that were not previously covered and to take on people who were rejected before because of their health.
Those who will pay more should take comfort in the knowledge that should they lose their jobs or face financial hardships or a medical crisis their previous policies would not have adequately covered, they would benefit from a health care safety net that offers federal subsidies and comprehensive coverage.
URL: http://www.nytimes.com/2013/11/11/opinion/high-and-low-premiums-in-health-care.html
LOAD-DATE: November 11, 2013
LANGUAGE: ENGLISH
DOCUMENT-TYPE: Editorial
PUBLICATION-TYPE: Newspaper
Copyright 2013 The New York Times Company
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The New York Times
December 7, 2016 Wednesday
Late Edition - Final
Addiction and Health Law
SECTION: Section A; Column 0; Editorial Desk; LETTER; Pg. 28
LENGTH: 231 words
To the Editor:
Re ''The G.O.P. and Health Care Chaos'' (editorial, ''What's at Stake'' series, Nov. 28): Repealing the Affordable Care Act will significantly undermine efforts to reduce addiction.
First, the 22 million people at risk of losing their health insurance have higher rates of substance use disorders than the general population. Second, the law requires health plans to offer addiction benefits and prohibits plans from imposing more restrictive limits or higher out-of-pocket costs on those benefits as compared with similar medical/surgical benefits.
These provisions in the health law are the strongest protections available for health care consumers seeking addiction treatment paid for by their insurance.
Our country is divided on many issues, including the health law, but there is widespread agreement that addiction is a major problem.
The Affordable Care Act is not a perfect law, but it offers some of the best tools available for increasing addiction treatment access. Whatever proposal the new administration puts forward should include similar or better provisions to ensure that people with addiction can get treatment.
We cannot stop the opioid epidemic if people do not have health insurance that covers treatment.
LINDSEY VUOLO
New York
The writer is associate director of health law and policy at the National Center on Addiction and Substance Abuse.
URL: http://www.nytimes.com/2016/12/06/opinion/addiction-and-the-health-law.html
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The New York Times
October 11, 2013 Friday
Late Edition - Final
Health Act Embraced Here, Kept at Arm's Length There: In Florida, Hostility By State and Snags In Online Sign-Ups
BYLINE: By LIZETTE ALVAREZ
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1037 words
MIAMI -- Be it gold, silver or bronze level, there are two ironclad requirements for buying health insurance in Florida on the federal online exchange: patience and persistence.
''Please wait,'' read the message on the exchange Web site. ''Your account cannot be created at this time,'' read another. Or, worse yet, an applicant's information simply vanished into the ether, and neither the 800 number nor the online chat session could reverse its disappearance.
''I had to take the day off work to come here,'' Liliana Cardenas said in frustration after sitting nearly two hours with a counselor at a health clinic in Hialeah, a mostly Cuban suburb of Miami, only to see her information disappear. ''I don't know when I can come back.''
And so it went in Florida, where access to health insurance under the Affordable Care Act may seem as elusive as compromise in Washington.
First the State Legislature roundly rejected the law, refusing to create a state insurance exchange and punting it to the federal government to run the new insurance market. It also rejected $51 billion in federal funds that was available over 10 years to expand Medicaid coverage for the state's poor. As the day neared for consumers to enroll in insurance plans, state officials announced that so-called navigators -- a group assigned to help people sign up -- would be barred from state health offices just like all other outside groups.
But blame this week shifted to the federal government. Its Web site remains so error-prone that the overwhelming majority of Floridians who have tried to buy affordable health insurance have had little luck. Anecdotal evidence across Florida, which has 3.5 million uninsured residents, the second highest in the country, indicated that few Floridians managed to enroll. Those who pushed past the pleas for patience often did so in the evening or early in the morning -- when Web site traffic is down.
There are no official numbers yet of how many people in Florida, or elsewhere, enrolled, tried to enroll or at least perused the offerings, but were unable to do so. The Obama administration said it would release the numbers once a month.
Florida is not the only state dealing with technical logjams. The 35 other states also using the federal government's exchange are experiencing similar problems, most of them related to a high volume of visitors and software problems. This is not the case for states like California, which organized their own exchanges.
At a recent stopover in Tampa, where she spoke about the continuing problems, Kathleen Sebelius, the secretary for Health and Human Services, acknowledged the Web site malfunctions but said that the federal government was ''working really around the clock'' to fix them.
''Should we have predicted it?'' Ms. Sebelius asked. ''Maybe we could have done a better job.''
The delay is particularly problematic in Florida because of its demographics. Hispanics make up 35 percent of Florida's uninsured population, above the national average. But the Obama administration also postponed the start of the Spanish-language Web site until Oct. 21, which means some Latinos cannot decipher the information on the insurance exchange without help.
Once they can, many Floridians will find an estimated 100 plans to choose from (some counties have more), which is nearly twice the national average. The prices and the benefits range from platinum level, which is the most expensive and covers the most costs, to bronze, the least expensive plan. The United States Centers for Medicare and Medicaid Services estimated that 53 percent of Floridians who are eligible for federal-exchange insurance can get subsidies, which reduces costs considerably.
Despite their state's opposition to the law, Floridians are finding help across the state from hundreds of certified application counselors, who usually work with community health centers. Navigators, who also provide help, remain a rare resource -- 62 had been approved statewide as of Tuesday, mostly because of stringent state and federal rules. Unlike some other states, Florida requires fingerprinting and criminal background checks for navigators.
Andrew Behrman, the president and chief executive of the Florida Association of Community Health Centers, said that some of the uninsured, faced with a maelstrom of software issues, may find it hard to carve out time to keep trying.
He is optimistic, he said, but recognizes that some people are losing patience. Many are walking away from clinics with appointments to come back on later dates rather than with subsidized health insurance policies. Work schedules could well prevent some from returning for help by the cutoff date in December.
''That is one of my concerns,'' Mr. Behrman said. ''The people that we are trying to help the most are the ones who would have to take time off work to do this.''
This week Ms. Cardenas stopped by the Jessie Trice Community Health Center in Hialeah to enroll with the help of a counselor. She needs bladder surgery and insurance.
Error after error popped up on the Web site. So they called the 800 number. An understanding operator on the line said she would personally enter Ms. Cardenas's information, and that of her family, into the site. That took nearly 90 minutes because of the snags. Suddenly, the 800 operator's screen went blank; the information had disappeared, not an uncommon occurrence.
The Trice counselor handed Ms. Cardenas an appointment card for December, the earliest she could return because of her work schedule.
''The woman on the phone just told me that everything she put in the system disappeared,'' said Ms. Cardenas, who works packaging medical equipment. ''I lost a day today from work to do this. I am totally frustrated.''
Sitting one office over, Emerly Guzman, a counselor, tried a different approach. She grappled with the site's live chat functions. ''Be patient while we're helping other people,'' the chat screen said. Next she called the 800 number, and got through. But the operator was also flummoxed. ''How long will it take before the glitches are fixes?'' Ms. Guzman asked her. ''I'm not really sure,'' the operator replied. ''We're even having trouble getting online applications here.''
URL: http://www.nytimes.com/2013/10/11/us/in-florida-opposition-by-the-state-and-snags-in-signing-up-on-the-web.html
LOAD-DATE: October 11, 2013
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GRAPHIC: PHOTOS: SNARLED WEB: Emerly Guzman, a health counselor, with a client at the Jessie Trice Community Health Center in Hialeah, Fla. She had trouble with the federal Web site's chat function and 800 number. (A12)
OFFLINE: Henry Echeverria tried to enroll for a health plan, but the federal Web site was down. (PHOTOGRAPHS BY MICHELE EVE SANDBERG FOR THE NEW YORK TIMES) (A16)
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The New York Times
April 19, 2014 Saturday
Late Edition - Final
How to Run on Health Reform
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 16
LENGTH: 486 words
The Republican attack machine, fueled by millions of dollars from the Koch brothers, has Democrats so rattled about the health reform law that many don't want to talk about it. They're happy to run on equal pay for women, or a higher minimum wage, or immigration reform -- all of which provide important contrasts with a do-nothing Republican Party -- but they haven't said much about the biggest social accomplishment of the Obama administration.
On Thursday, President Obama had a suggestion for them: How about standing up for the Affordable Care Act? Democrats, he said at a news conference, ''should forcefully defend and be proud of the fact that millions of people'' have been helped by the law -- people who now have health insurance for the first time, or were not kicked off a policy when they got sick, or who can now leave a job without fear of being uninsured. ''I don't think we should apologize for it, and I don't think we should be defensive about it,'' he said. ''I think there is a strong, good, right story to tell.''
Eight million people have now signed up for insurance on the new health care exchanges, the president announced, a milestone that seemed out of reach last fall when the federal website wasn't working and Republicans were jeering at that fiasco. Not only are the overall numbers strong, but a substantial portion of the sign-ups -- 28 percent, so far -- are between the ages of 18 and 34, a sign that healthy people are joining the system, which will help keep premiums affordable. That number should ideally be a little higher, but it is an unmistakable refutation of the predictions of failure from health care reform's opponents.
''This thing is working,'' Mr. Obama said.
That's exactly the right tone to take, and the White House itself has been slow to take it, uncertain until a few weeks ago whether the law's most basic goals would be met. Now that the law is proving to be even more successful than expected, it's time for Democratic congressional candidates to remind voters what government can accomplish.
Some of the Democratic super PACs are already doing that for their candidates, running ads pointing out that Republicans want to return to a health insurance system that allows women to be charged more, or allows sick people to lose their policies. But rather than rely on the unlimited money of super PACs to do the job, the candidates should be doing it themselves.
They can point out, as Mr. Obama did, that House Republicans have taken many votes to repeal the health law -- and yet they have not voted on a single measure that would put people back to work rebuilding roads and water plants.
It's important to move on to jobs and the economy, as Mr. Obama urged Congress to do. But first voters need to be reminded that government programs can improve life for all Americans. When one of those programs begins to do its job, its authors shouldn't be afraid to say so.
URL: http://www.nytimes.com/2014/04/19/opinion/showing-pride-in-health-reform.html
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The New York Times
October 2, 2013 Wednesday
Late Edition - Final
Technical Woes on Web Site
BYLINE: By NICK BILTON
SECTION: Section A; Column 0; National Desk; IN PRACTICE; Pg. 15
LENGTH: 590 words
While the federal Affordable Care Act is intended to narrow the divide between those with health care and those without, in its first day of operation the Web site aimed at helping consumers sign up for health insurance -- Healthcare.gov -- might have driven a larger wedge between technologically adept Americans and those who have yet to fully embrace the social Web and mobile technology.
The site encouraged people to ''connect'' via Twitter, Facebook and YouTube. It also provided a phone number to call, but doing so resulted in a long wait for assistance.
While the site's search feature seemed very intuitive, often returning detailed results for queries, including ''sign up for account'' or ''sign up for coverage,'' some questions returned a blank page that simply said ''No Results.'' In a bit of unintentional irony, the page then asked if an answer was helpful.
Those who did make it onto the Web site seemed to appreciate the design and aesthetics. The site looks like one for a typical start-up, with clean typography and large identifiable buttons that provide direction. Unlike most government sites, Healthcare.gov feels like it was built for today's Web users, rather than something that still belongs in a 1990s-era Web browser.
Perhaps the best experience for exploring and signing up for the Web site is on a smartphone; the site looks beautiful and is simple to navigate on an Apple iPhone and devices using Google's Android operating system. People can even sign up for the service on the mobile Web site, not just browse FAQs as is the case on the mobile sites of most other government agencies.
But not everyone was happy with the look and feel of the overall experience. Some complained that the site was too busy and complex, and that navigation was baffling.
''The http://healthcare.gov site is kind of confusing,'' Gilly Wonka of Georgia wrote on Twitter. A friend instantly replied to Mr. Wonka, adding a single word: ''Very!''
While the site took three years to build, it took only a few minutes for it to break down when it went live at 8 a.m. E.D.T.
Some consumers said they were met with an error message in the early morning when trying to visit the Web site, which seemed to be overwhelmed with traffic and limited by apparent programming issues.
Many people took to Twitter and Facebook to note that the site was down.
''And http://healthcare.gov is already broken ...'' Kelly Campbell, a software engineer for Philadelphia, wrote on Twitter. ''Can't sign up for an account because all the security question options are blank.''
Ms. Campbell was referring to a series of three security questions that were showing up blank for some people, a series of question marks and programming code to others, or simply as error messages.
One of the site's error messages read: ''We have a lot of visitors on our site right now and we're working to make your experience here better. Please wait here until we send you to the login page. Thank you for your patience!'' Another declared: ''The system is down at the moment. We're working to resolve the issue as soon as possible. Please try again later.''
In a statement, Healthcare.gov officials said they were aware of the problems and working to fix them.
''Thanks for all your comments and updates as you enroll. We apologize that wait times on the site and hotline are longer than expected!'' the agency said. ''We're working to fix these issues as soon as possible. Thanks for your patience.''
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/news/affordable-care-act/2013/10/01/in-debut-affordable-care-web-site-baffles-many-users/
LOAD-DATE: October 2, 2013
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GRAPHIC: PHOTO: The HealthCare.gov site stumbled in its first day and gave many visitors error messages. (PHOTOGRAPH BY KAREN BLEIER/AGENCE FRANCE-PRESSE -- GETTY IMAGES)
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The New York Times
July 3, 2015 Friday
Late Edition - Final
Medicare and Medicaid at 50
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 20
LENGTH: 818 words
Medicare and Medicaid, the two mainstays of government health insurance, turn 50 this month, having made it possible for most Americans in poverty and old age to get medical care. While the Affordable Care Act fills the gap for people who don't qualify for help from those two programs, there are important improvements still needed in both Medicare and Medicaid.
At the time the two programs were enacted in July 1965, advocates of Medicare, which today covers 46 million Americans over the age of 65 and nine million younger disabled people, expected that it would expand to cover virtually all Americans. Although polls between 1999 and 2009 showed consistent majorities in favor of expanding Medicare to people between the ages of 55 and 64 to cover more of the uninsured, it never happened.
Still, its achievement in improving life expectancy and reducing poverty among the elderly has been enormous. Before Medicare, almost half of all Americans 65 and older had no health insurance. Today that number is 2 percent. Analysts say that between 1970 and 2010, Medicare contributed to a five-year increase in life expectancy at age 65, by providing early access to needed medical care. Even compared with people under age 65 who have insurance, those on Medicare are less likely to miss needed care or have unmanageable medical bills.
While Medicare, which covers hospital care, doctors' services and prescription drugs, is comprehensive, many people are still left struggling to pay premiums, cost-sharing for various services and the full cost of items not covered by Medicare, like dental care and extended stays in nursing homes. Roughly half of all Medicare recipients live on incomes of less than $24,000 per person, and while the poorest of them get additional help from Medicaid, many do not. Medicare still lacks a cap on the amount a beneficiary has to pay out of pocket, the most basic function of insurance. By contrast, the Affordable Care Act puts limits on beneficiary spending per year and over a lifetime.
The Affordable Care Act has helped Medicare beneficiaries by eliminating co-payments and deductibles for preventive care like mammograms and colonoscopies, and by providing discounts for very heavy users of prescription drugs. It will strengthen Medicare as a system through demonstration projects to find new ways to deliver care that will improve its quality and lower its cost. The challenge will be to identify and spread the most promising innovations so that they benefit not just Medicare, but the entire health care system.
Medicaid, the other part of the medical safety net, is a joint state-federal program for the poor. For the past five decades, it has been critical in reducing childhood deaths and infant mortality. It has saved the lives of patients with chronic conditions like heart disease, diabetes and asthma. Last year it covered some 64 million people in a typical month and 80 million people at some point during the year. If Medicaid did not exist, life expectancy in America would be much lower.
The problem with Medicaid is that federal rules give states great leeway in deciding whom the program helps. Many states are so cheap that only extremely poor parents qualify for Medicaid coverage and childless adults are excluded entirely. Texas, for example, only covers parents who earn up to 15 percent of the federal poverty level, or less than $4,000 a year for a family of four, and does not cover other non-disabled adults at all, while other states, including New York and California, offer far better coverage. The result is huge differences across the country for assistance to poor, sick people.
The Affordable Care Act was intended to reduce this disparity by offering additional federal funding for states to expand their Medicaid programs to cover all adults up to 138 percent of the federal poverty level, or $32,913 for a family of four. Yet 21 states, the vast majority run by Republican governors, have chosen not to expand.
Medicaid could be improved by raising its payments to doctors, who often refuse to take Medicaid patients because the rates are so low compared to private insurance and Medicare. Medicaid should also cover legal immigrants, who currently have to wait five years to be eligible, and illegal immigrants, who are currently denied coverage entirely.
Despite the perennial fear that the costs of these two programs will grow uncontrolled, spending in both has been growing at a relatively modest rate in recent years. Medicare and Medicaid have changed and grown over the decades, through Republican and Democratic administrations, to meet new challenges. Their performance and popular support has allowed them to withstand ideologically-driven attacks on their continuance as government entitlements. These programs succeed, in fact, because they entitle all eligible Americans to receive the health care they need.
URL: http://www.nytimes.com/2015/07/03/opinion/medicare-and-medicaid-at-50.html
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The New York Times
February 13, 2016 Saturday
Late Edition - Final
Clinton Revs Up Attacks on Sanders in South Carolina
BYLINE: By JONATHAN MARTIN and ALAN RAPPEPORT; Jonathan Martin reported from Denmark, and Alan Rappeport from Washington.
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 929 words
DENMARK, S.C. -- Hillary Clinton forcefully attacked Senator Bernie Sanders before a heavily black audience Friday, highlighting his criticism of President Obama, the Affordable Care Act and for what she suggested was a single-minded focus on economic fairness at the expense of racial justice.
One day after the two squared off at a debate that emphasized issues relating to race and gender, Mrs. Clinton made clear that she intends to run in this state's primary by effectively seeking Mr. Obama's third term -- and claiming Mr. Sanders would be a threat to the first black president's accomplishments.
''He has called the president weak, a disappointment. He tried to get some attention to attract a candidate to actually run against the president when he was running for re-election,'' Mrs. Clinton told a gymnasium full of voters near the campus of a historically black college here.
It was a reprisal of her offensive at Thursday night's debate, but she escalated her assault further, portraying Mr. Sanders as an impediment to the health care law so associated with Mr. Obama that, she noted, it bears his name.
''He does not support the way I do building on the progress the president has made, and that includes building on the Affordable Care Act,'' she said of her opponent, receiving a loud ovation when she mentioned Mr. Obama's signature domestic accomplishment. It is African-Americans, she added to more applause, who ''have made the most advances and gains'' thanks to the health law.
Mrs. Clinton's assault was an indication of how aggressively she intends to run against Mr. Sanders, who routed her by 22 percentage points in the New Hampshire primary this week. Separately, the ''super PAC'' supporting her, Priorities USA, said it would begin running ads that Mrs. Clinton is the true heir to Mr. Obama's legacy when it comes to helping blacks.
The electorate in the South Carolina Democratic primary on Feb. 27 is expected to be at least half black, a constituency that reveres Mr. Obama and was crucial in his defeat of Mrs. Clinton in the 2008 Democratic contest here.
Mrs. Clinton still enjoys a substantial advantage over Mr. Sanders among African-Americans in polls, but her campaign is plainly concerned about his making inroads with such voters. Her campaign has conducted focus groups of African-American voters, an aide said, which revealed that many of them associate attacks on the health law as no different from attacks on Mr. Obama himself.
Mr. Sanders voted for the legislation, but has called for going further and enacting universal, government-run health care for all Americans.
''Clearly, after Iowa and New Hampshire, the Clinton campaign is getting very nervous and is becoming increasingly negative and desperate,'' said Michael Briggs, a spokesman for Mr. Sanders. ''The simple truth is that there are very few in Congress who have a stronger civil rights record than Senator Sanders.''
Mrs. Clinton's strategy appears to be to wage a multipronged set of attacks on Mr. Sanders as the battle moves to South Carolina and the rest of the South.
Provoking old memories of politicians bearing false hope, she suggested that Mr. Sanders was setting voters up for a letdown with his ambitious proposals.
''I want you to understand: I will not promise you something that I cannot deliver,'' she said. ''I will not make promises I know I cannot keep. We don't need any more of that.''
More broadly, Mrs. Clinton is effectively seeking to turn Mr. Sanders's grounding in class-based politics into a liability, suggesting that he is insufficiently focused on the immediate problems of black voters whose quality of life will not be lifted by curbing Wall Street excesses or reforming the campaign finance system.
''I'm not a single-issue candidate, and this is not a single-issue country,'' she said to applause. ''If we enacted our toughest plans to rein in Wall Street and shadow banking and all the other abuses we are concerned about, I'd worry we'd still have lead in the water in Flint and we'd still have deteriorating schools here in South Carolina.''
Mrs. Clinton's remarks came in a poor, rural region of South Carolina that drew national attention when a 2005 documentary called ''Corridor of Shame'' was filmed here about its dilapidated schools.
Mrs. Clinton noted to the audience that she has a history here: She visited the county Denmark is in when she worked for the Children's Defense Fund in the early 1970s and came to the South to investigate the treatment of juvenile offenders who were imprisoned with adult criminals.
Despite the fact that Mrs. Clinton has led in most South Carolina polls, Priorities USA is leaving nothing to chance there. The group announced on Friday that it would spend $500,000 on its radio ads in the state, its largest advertising campaign to date on her behalf.
''We need a president who will build on all that President Obama has done,'' say the narrators of the ad, which will air in South Carolina communities with large black populations. ''President Obama trusted Hillary Clinton to be America's secretary of state. And we know Hillary Clinton has the vision and courage to help build an economy to support our communities.''
The new push from Priorities USA could leave Mrs. Clinton open to more criticism from Mr. Sanders, who has lamented her reliance on big donors as a sign that she is not independent.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
URL: http://www.nytimes.com/2016/02/13/us/politics/hillary-clinton-sharpens-focus-after-democratic-debate-tussles.html
LOAD-DATE: February 13, 2016
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GRAPHIC: PHOTOS: Hillary Clinton spoke at an elementary school on Friday in Denmark, S.C. The state's Democratic primary will be held Feb. 27. (PHOTOGRAPH BY STEPHEN B. MORTON FOR THE NEW YORK TIMES)
Senator Bernie Sanders after a campaign event Friday in St. Paul. Mrs. Clinton says he has called President Obama ''weak.'' (PHOTOGRAPH BY EVAN VUCCI/ASSOCIATED PRESS)
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The New York Times
September 19, 2013 Thursday
Late Edition - Final
Pressed From His Right, Speaker Yields on a Budget Showdown
BYLINE: By JONATHAN WEISMAN; Ashley Parker contributed reporting.
SECTION: Section A; Column 0; National Desk; CONGRESSIONAL MEMO; Pg. 18
LENGTH: 1113 words
WASHINGTON -- After three years of cajoling, finessing and occasionally strong-arming his fitful conservative majority, Speaker John A. Boehner waved the white flag on Wednesday, surrendering to demands from his right flank that he tie money to keep the government open after Sept. 30 to stripping President Obama's health care law of any financing.
Mr. Boehner knows that the plan he unveiled cannot pass the Senate, and that it may prove unwise politically and economically. His leadership team pressed just last week for an alternative. But with conservative forces uniting against him, he ultimately saw no alternative but to capitulate -- and few good options to stop a government shutdown in two weeks.
''Today was a step forward, and a win for the American people,'' said Representative Tom Graves, the Georgia Republican whose ''defund Obamacare'' push had amassed 80 House supporters, a bloc large enough to dictate the outcome.
With much of the government set to run out of money at the end of the month -- and run out of borrowing authority by mid-October -- Mr. Boehner faced a choice: he could steer a middle ground and find a way out of his fiscal dead end with Republican and Democratic votes, or he could yield to a conservative movement to strip the Affordable Care Act of financing, unite his Republican majority around that war cry, and hope for the best.
House conservatives let Mr. Boehner know that any solution that could not attract a majority of the Republican conference could cost him his speakership. Divided Senate Republicans made clear that linking further government spending or a debt ceiling increase to gutting the health care law would never get through the Senate.
In March, the speaker himself said: ''Do you want to risk the full faith and credit of the U.S. government over Obamacare? That's a very tough argument to make.''
On Wednesday, the speaker announced his choice.
''The law's a train wreck,'' he said. ''It's time to protect American families from this unworkable law.''
The House's stopgap spending measure would finance the government through Dec. 15 at the current spending levels, which reflect the automatic spending cuts that took effect in March, known as sequestration, while blocking the health care law, under which the uninsured will be enrolled beginning on Oct. 1.
If the bill clears the House on Friday, Republican leaders could put forward a measure as soon as next week that would raise the government's statutory borrowing limit. That bill would also take aim at the Affordable Care Act, with a one-year delay of its provisions coupled with a one-year increase in the debt ceiling. It would also expedite the construction of the Keystone XL oil pipeline from Canada to Louisiana and set a timeline for an overhaul of the federal tax code, and possibly include some other Republican wishes, like specific spending cuts and regulatory changes.
For Mr. Boehner, the announcement Wednesday was a humbling moment, and possibly a defining one. Since the Tea Party wave swept Republicans to power in 2010, the beleaguered speaker has often found himself at odds with the most conservative wing of his conference. In late 2011, he famously put his fractious conference on mute as he explained via telephone how it had to give up its opposition to extending a cut in the payroll tax.
Three times this year, on major pieces of legislation, the speaker has put what he believed to be the greater needs of his country and his national party over those of his recalcitrant right wing. In January, the House passed legislation to avert huge and sudden tax increases on virtually every American -- but let taxes rise on the wealthy -- with Democratic votes and a minority of votes by Republicans. The same math passed relief for Hurricane Sandy and a reauthorization of the Violence Against Women Act.
This time around he was contrite, quoting a plaque that graced the speaker's office of Newt Gingrich: Listen, Learn, Help and Lead.
''The key to any leadership job is to listen,'' Mr. Boehner said.
Mr. Gingrich, of course, was deposed by an angry coup after Republicans lost seats in midterm elections during the second term of the last Democratic president, Bill Clinton. This time, the ground troops simply got their way with Mr. Boehner, providing new evidence that the Tea Party has changed Washington, not the other way around.
As has been the case with each fiscal crisis since the Republicans took control of the House, Mr. Boehner's decision was an embrace of short-term tactics over long-term strategy. How either the spending or the debt limit measures will become law is anybody's guess.
''Look, I think you could get all of us in the Senate to support it,'' Senator John Hoeven, Republican of North Dakota, said of his Senate Republican colleagues. ''The problem is, what is the Democrat majority going to do with it? That's the challenge.''
Even the man who started the ''defund Obamacare'' boomlet, Senator Ted Cruz, Republican of Texas, seemed to accept Senate reality on Wednesday, putting the onus on House Republicans to stand and fight.
''Harry Reid will no doubt try to strip the defund language from the continuing resolution, and right now he likely has the votes to do so,'' Mr. Cruz said. ''At that point, House Republicans must stand firm.''
Mr. Obama was visibly irked by the speaker's decision. ''You have never seen in the history of the United States the debt ceiling or the threat of not raising the debt ceiling being used to extort a president or a governing party, and trying to force issues that have nothing to do with the budget and have nothing to do with the debt,'' he said at the Business Roundtable, which represents the chief executives of the nation's largest companies.
Even the U.S. Chamber of Commerce, a consistent ally of the Republican majority, questioned the House's course.
Democrats were gleeful at the potential political consequences. Representative Steve Israel of New York, the chairman of the Democratic Congressional Campaign Committee, said House Republicans set off Wednesday on a kamikaze mission, with their speaker in the pilot's seat. ''They're living in right-wing fantasy land'' if they expect Democrats to take the blame for the chaos that could ensue, he said.
But victorious House conservatives did their end-zone dance and evinced no worries about the final outcome.
''Even the best coaches in the N.F.L. only script out the first two series of plays,'' said Representative Jim Jordan, Republican of Ohio, when asked how the speaker would play out the sequence of events. ''They don't script the whole game. We've got to play the game. We've got to see how it all shakes out.''
URL: http://www.nytimes.com/2013/09/19/us/politics/house-gop-to-tie-spending-bill-to-health-law-defunding.html
LOAD-DATE: September 19, 2013
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GRAPHIC: PHOTO: Speaker John A. Boehner, right, with Representative Eric Cantor, the No. 2 House Republican, spoke about the budget on Wednesday. (PHOTOGRAPH BY GABRIELLA DEMCZUK/THE NEW YORK TIMES) (A19)
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The New York Times
October 3, 2013 Thursday
Late Edition - Final
Health Exchanges, Open for Business
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 30
LENGTH: 497 words
To the Editor:
Re ''Opening Rush to Insurance Markets Hits Snags'' (front page, Oct. 2):
On Tuesday, millions of Americans voted with their mice. Obamacare is here to stay, and the Republican Party is wrong to stand in its way; Republicans will increasingly pay a political penalty for their opposition as more and more Americans come to realize the benefits of Obamacare.
ORIN HOLLANDER Jamison, Pa., Oct. 2, 2013
To the Editor:
Your Oct. 2 front-page article says that more than 2.8 million people tried to sign up for the new health care system and that many were frustrated by error messages and such.
I tried to sign up. I had absolutely no difficulty getting all the answers I needed and all the forms to fill out on the very first try. The entire process was simple, direct and easy to follow.
Don't forget all of us who, while maybe not newsworthy, are a large part of the equation.
HU LINDSAY Norwalk, Conn., Oct. 2, 2013
To the Editor:
Sadly, the Republicans will fail to notice that the ''jamming'' of the health care enrollment Web sites is a result of Americans' seeking health care coverage. Instead, they continue to prevent our Republic from moving forward toward justice and equality for all.
MARJORIE GEIGER Albany, Oct. 2, 2013
To the Editor:
Perhaps a compromise to help end this crisis would be to pass a clean continuing resolution and agree on an independent committee to evaluate the Affordable Health Care Act and make changes as needed.
Those who have a stranglehold on our economy and health might just be proved wrong.
PAMELA GROSS North Miami Beach, Oct. 2, 2013
To the Editor:
I voted for Barry Goldwater and Ronald Reagan. I own a small business. Surprise: I'm all for Obamacare. Why? Because no one in our country should lack proper medical care, especially children.
Right now, people who cannot afford preventive care wind up in the medical facility of last resort, the emergency room. That's expensive, and we all foot the bill.
We cannot be an exceptional country if we are an unhealthy country. We cannot be an exceptional country if our citizens have to travel abroad for affordable medical care. An exceptional country must also be a compassionate country.
LEW HOFF New York, Oct. 2, 2013
To the Editor:
When Apple's Web site crashes because of demand for a new version of the iPhone, it is not because people hate iPhones.
The interest in the health care exchanges must be the extreme Republicans' worst nightmare.
ANNE STEINMANN Santa Barbara, Calif., Oct. 2, 2013
The writer is a retired physician.
To the Editor:
Re ''Those Banana Republicans,'' by Joe Nocera (column, Oct. 1):
If the Affordable Health Care Act does in fact deliver affordable health insurance in an efficient manner, then indeed the Republicans will properly be deemed ''crazies.''
If, on the other hand, the law proves to be an administrative nightmare and health insurance costs spiral gradually and substantially up, then the Republicans will be deemed wise men.
GERALD H. ABRAMS New York, Oct. 1, 2013
URL: http://www.nytimes.com/2013/10/03/opinion/health-exchanges-open-for-business.html
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The New York Times
May 7, 2014 Wednesday
Late Edition - Final
Insurers Say Most Who Signed Up Have Paid Up
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 691 words
WASHINGTON -- Most of the people choosing health plans under the Affordable Care Act -- about 80 percent -- are paying their initial premiums as required for coverage to take effect, several large insurers said Tuesday on the eve of a House hearing about the law.
But the health insurance industry said the total of eight million people who signed up included ''many duplicate enrollments'' for consumers who tried to enroll more than once because of problems on the website.
''Insurers have many duplicate enrollments in their system for which they never received any payment,'' said Mark Pratt, a senior vice president of America's Health Insurance Plans, an industry trade group.
''It may be a matter of months,'' Mr. Pratt added, ''before insurers know how many people activated their coverage by paying their share of premiums.''
President Obama said last month that eight million people had signed up for health insurance under the Affordable Care Act, surpassing the administration's original goal of seven million in the federal and state insurance exchanges.
In testimony prepared for a hearing of a panel of the House Energy and Commerce Committee on Wednesday, Mr. Pratt said, ''Health insurers have been doing everything possible to encourage exchange enrollees to pay their premiums.''
Paul Wingle, the executive director of exchange operations and strategy at Aetna, said: ''As of the third week of April, Aetna had over 600,000 members who had enrolled and roughly 500,000 members who had paid. For those who had reached their payment due date, the payment rate, though dynamic, has been in the low- to mid-80 percent range.''
Aetna said it was selling insurance to individuals and families in the exchanges of 17 states.
The Obama administration extended deadlines for people to sign up and pay for insurance, making it difficult to establish an accurate count of enrollment, insurers said. The federal government is still working on a financial management system to reconcile enrollment records of insurers and the exchanges.
J. Darren Rodgers, the chief marketing officer of the Health Care Service Corporation, which offers Blue Cross and Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas, said his company had received 600,000 applications through the exchanges in Texas and the four states it serves. On average, according to data provided by Mr. Rodgers, about 15 percent of customers missed their initial payment deadlines from January through April.
About two-thirds of Aetna subscribers with exchange policies scheduled to take effect on May 1 have paid their premiums, Mr. Rodgers said, but some of the others have more time to pay.
Dennis Matheis, the executive in charge of exchange strategy for WellPoint, said the company was satisfied with returns on its business in the 14 states where it was selling health plans on the exchanges.
''We are seeing strong membership growth and large percentages of our newly enrolled customers are successfully paying their premiums by the due date,'' Mr. Matheis said.
For people who signed up from Oct. 1 to April 15, Mr. Matheis said, about 70 percent have paid their premiums. For people who have passed the payment deadline, he said, the proportion is higher, ''ranging up to 90 percent, depending on the state.''
Republicans on the committee said last week that only about two-thirds of people signing up for private health insurance in the federal exchange had paid their premiums as of April 15. Administration officials and congressional Democrats called that statistic grossly misleading. Given the surge in enrollment near the end of March, they said, it is understandable that some policyholders would not have paid by April 15.
Frank E. Coyne a vice president of the Blue Cross and Blue Shield Association, said 283,800 people had signed up for coverage offered by ''multistate plans'' sold by Blue Cross and Blue Shield under contract with the federal government.
Congress authorized the multistate insurance program to increase options for consumers shopping in the online insurance markets. The plans are available in the marketplaces, or exchanges, of 30 states.
URL: http://www.nytimes.com/2014/05/07/us/politics/insurers-say-most-who-signed-up-under-health-law-have-paid-up.html
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The New York Times
January 8, 2016 Friday
Late Edition - Final
Administration Optimistic About Health Plan Goal
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 845 words
WASHINGTON -- The Obama administration said Thursday that 11.3 million people had signed up for health insurance so far during the Affordable Care Act's third open enrollment period, with indications of a strong desire for coverage among young adults and others who were not enrolled last year.
''We're seeing unprecedented demand for marketplace coverage,'' said Sylvia Mathews Burwell, the secretary of health and human services, who released the data just hours after the Republican-controlled Congress cleared legislation to repeal the health care law.
About 8.6 million people have signed up or been automatically re-enrolled in the 38 states that use HealthCare.gov, the website for the federal insurance marketplace, federal officials said. In states running their own exchanges, 2.7 million people have signed up.
The current open enrollment period ends Jan. 31. Many people who select health plans later fall off the rolls because they fail to pay their share of premiums or find other coverage. With three weeks left, the administration appears to be on course to meet its goal of having 10 million people enrolled at the end of this year.
Of 11.3 million people who had selected health plans, about 3 million, or 26.5 percent, were 18 to 34, the group most sought by insurance companies. That is similar to the 28 percent share reported at the end of open enrollment in 2014 and 2015.
Andrew M. Slavitt, the acting administrator of the Centers for Medicare and Medicaid Services, which runs the federal marketplace, said that in the days remaining before the Jan. 31 deadline, he expected to see ''a rush of younger people, who are much more procrastinators.''
Still, the final tally of young adults seems most likely to fall below the 35 percent level that Kevin J. Counihan, the chief executive of the federal insurance marketplace, said was considered ''a good optimal number'' when he ran the state insurance exchange in Connecticut.
Many insurers would like to see a larger proportion of young adults, whose premiums help defray the costs of care for older, less healthy consumers.
Supporters and opponents of the Affordable Care Act appear to be looking at different laws. As administration officials were announcing the new figures, Speaker Paul D. Ryan of Wisconsin was officially signing repeal legislation to be sent to President Obama for his promised veto.
Mr. Ryan declared that the law would collapse under its own weight or be repealed with the help of a Republican president. ''We are confronting the president with the hard, honest truth,'' he said. ''Obamacare does not work. It has to go. Higher premiums, fewer choices, restricted access -- these are not signs of success. These are signs of failure.''
Administration officials said they were pleased to see substantial numbers of new consumers shopping for insurance this year, and Mr. Counihan said that the higher penalties for going without insurance appeared to be ''a very strong motivator for people to enroll.''
New consumers accounted for 29 percent of people selecting health plans in the federal marketplace, but only 19 percent in the state insurance exchanges.
Officials said they did not know how many of the 11.3 million people signing up in the federal and state marketplaces were previously uninsured. More than eight out of 10 people obtaining insurance in the exchanges qualified for federal subsidies to help pay their premiums.
A report by the administration portrays marketplace consumers as savvy shoppers, much more likely than people with employer-sponsored insurance to switch to a different health plan.
More than 3.6 million people who had coverage in 2015 returned to the federal exchange and actively selected a plan for 2016, rather than being automatically re-enrolled. About 60 percent of this group -- 2.2 million people -- enrolled in a different plan for 2016.
Two factors may help explain these choices. Consumers in the federal and state marketplaces are keenly attentive to prices, and they may have to shift to new plans to avoid big increases in the premiums. In addition, the Obama administration has created online tools that make it easier for consumers to compare their total out-of-pocket costs under different health plans.
The administration has made some progress in signing up Latinos, but still appears to be struggling to enroll African-Americans. Among people choosing health plans for whom racial and ethnic information was available, 14 percent were Latinos and 11 percent were African-American, the administration said.
In each of three states, more than a million people have signed up for coverage through an insurance marketplace, and together they account for more than one-third of all sign-ups. Florida, with nearly 1.6 million people selecting health plans, and Texas, with 1.1 million, use the federal marketplace. California, with 1.4 million, operates its own exchange.
Follow the New York Times's politics and Washington coverage on Facebook and Twitter, and sign up for the First Draft politics newsletter.
URL: http://www.nytimes.com/2016/01/08/us/politics/obama-administration-optimistic-about-health-plan-goal.html
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The New York Times Blogs
(Paul Krugman)
February 26, 2014 Wednesday
A General Theory of Obamacare Fiction
SECTION: OPINION
LENGTH: 493 words
HIGHLIGHT: Why you know not to believe the sob stories.
Conservatives appear to be really upset that liberals are actually taking on the facts in the anti-Obamacare ads they've been running. How dare you question whether the people in these ads are giving an accurate picture - they're suffering!
OK, we've seen this kind of play before. Remember how anyone suggesting that Dick Cheney and whatshisname misled us into invading Iraq was attacking American's brave fighting men and women?
But there's a different kind of struggle anyone trying to point out the facts encounters - a barrage of anecdotes. You say that the Obamacare horror stories are fake, but I kind of know this man who is being told that he has to buy a policy he can't possibly afford / I read this sad story in the Wall Street Journal / I heard this tale on the radio / etc..How do you answer that?
Well, it can't be done retail. If the Koch brothers are pouring money into ads featuring a person, or the GOP response to the SOTU tells a story, then it's worth trying to track down the particulars of this case. But to deal with the broader problem of anecdotes, what you need is a framework that tells you which anecdotes are almost surely wrong.
So here's what you need to understand. The Affordable Care Act isn't magic - it produces losers as well as winners. But it's not black magic either, turning everyone into a loser. What the Act does is in effect to increase the burden on fortunate people - the healthy and wealthy - to lift some burdens on the less fortunate: people with chronic illnesses or other preexisting conditions, low-income workers.
Suppose, then, that someone comes to you with an anecdote about a cancer patient, or just an older person in poor health, and tells you that this person is about to lose the care she needs, or face a huge increase in expenses, under Obamacare. Well, it's almost certainly not true - people like that are overwhelmingly beneficiaries of health reform, thanks to community rating, which means that they can't be discriminated against because of their condition.
Or suppose that someone tells you about a struggling worker who had adequate coverage but is now being confronted with unaffordable premiums. You should immediately ask, what about the subsidies? Because the Affordable Care Act has subsidies that are there specifically to keep premiums affordable for lower earners.
If someone insists that he knows about someone in these categories who really is being grievously hurt, well, the burden of proof rests with the claimant. Basically, stories like that are going to be very rare.
Obamacare opponents could, of course, go with the real losers - people in the one percent paying higher taxes, healthy young men who are getting by with cheap, minimalist policies. But they want sob stories - the sick middle-aged woman facing tragedy. And so far, every single one of those sob stories has turned out to be false - because the very nature of the reform is such that such things hardly ever happen.
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The New York Times
November 19, 2015 Thursday
Late Edition - Final
Now, Finding a Health Plan Is Annual Rite for Shoppers
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 1265 words
WASHINGTON -- For 2014, the first year she got health coverage through the Affordable Care Act, Gail Galen chose a plan from a new nonprofit insurer, Oregon's Health CO-OP. But the price jumped for 2015, so Ms. Galen switched to a policy from a different company, LifeWise Health Plan.
Now, with open enrollment for 2016 underway, she is preparing to leap to her third insurer in three years -- and stocking up on whiskey, she says, only half in jest, as she braces for another round of shopping on the federal insurance marketplace.
''Every year I feel like I'm starting all over again, and I just dread it,'' said Ms. Galen, 63, of Warrenton, Ore. ''My stress level just shoots up.''
Over the past two years, the Affordable Care Act has created entirely new markets for health insurance, and a new way of buying it, via online exchanges that allow comparison shopping. They have brought coverage to nine million people, many of whom could not afford it or were rejected by insurers before. But these new markets have also seen sharp price swings, or changes in policies, that are driving many consumers to switch plans each year.
The Obama administration is encouraging switching as a way to avoid steep increases in premiums -- and to promote competition among insurers, as the law intends. Next year will be no different: The price of plans will rise in most states, and the administration says that 86 percent of people who currently have coverage through the federal exchange can find a better deal by switching.
''This may be just one of those environments where there's a new normal,'' said Sabrina Corlette, a professor at the Health Policy Institute of Georgetown University.
For many consumers, the volatility in the markets has been a source of anxiety and disruption. To have any choice at all is a welcome development, many say. But switching plans is also becoming an unwelcome ritual, akin to filing taxes, that is time-consuming and can entail searching for new doctors and hospitals each year.
''I don't have a regular doctor anymore, so I avoid going,'' said David Saphier, a self-employed technology consultant in Manhattan who will be switching to his third exchange plan for 2016.
Some experts have raised concerns that frequently switching doctors could result in worse health care, though carefully controlled research on the issue is sparse.
Dr. Joseph Ladapo, a physician and health policy researcher at New York University School of Medicine, said it could be problematic in part because new providers often cannot get a patient's old medical records. Doctors also may feel less invested in the health of patients they believe are with them only for the short term, he added.
''It's going to be a challenging issue to really parse out,'' Dr. Ladapo said. ''But it's a very important one, and in general, any breaks in continuity that happen as a result of these narrowing networks or plan changes are probably not in the best interest of patients.''
The annual changes in plans and prices are a result of the many unknowns in the new markets. Insurers are changing their pricing, often significantly, year to year as they struggle to figure out how healthy or sick their new customers are. In some cases, insurers tried to get a foothold in the market with unsustainable low prices that they now must raise.
An additional factor for 2016 is the closing of a dozen nonprofit cooperative insurers that had more than 500,000 customers around the country. Those consumers will have no choice but to find a new plan, as will others whose insurers are leaving the exchange markets because they were losing too much money.
In Nashville, Alyssa Bernhardt learned recently that her plan from BlueCross BlueShield of Tennessee would rise to $115 a month even after her federal subsidy, from $45. She logged onto HealthCare.gov last week and found a comparable plan that will cost only $40 a month. She has switched plans every year since the exchanges opened, though she has managed to stay with Blue Cross Blue Shield all along.
''It's so confusing,'' said Ms. Bernhardt, 28, a graduate student and part-time consultant. ''It would be a lot easier if I could just renew the same plan.''
Last year, many people did just that, taking no action and letting their coverage automatically renew for 2015. Still, about half of returning HealthCare.gov customers at least shopped around before settling on a health plan, and about 25 percent switched -- far more than many experts predicted. Those who switched insurers but kept the same level of coverage ended up saving about $490 over the course of the year in premium costs, according to a report by the Department of Health and Human Services.
As much as they dislike switching plans, people like Ms. Galen, who has a history of skin cancer, say it is far preferable to what they faced before the health law took effect. Then, many people with medical conditions could not get insurance or had to pay much more for it, and they clung to whatever coverage they could get because if they tried to switch to a different insurer, they would most likely be rejected.
Mary Stuart, 64, of Omaha, has already switched to Assurant from Blue Cross and Blue Shield of Nebraska, and so far has been able to keep her doctors. Now Assurant is leaving the exchange market, and Ms. Stuart is intent on finding a new plan that will cover the ophthalmologist who treats her macular degeneration, a serious eye disease.
''I'm like, oh God, here we go again,'' said Ms. Stuart, who does not receive a premium subsidy and pays $890 a month for her current plan.
On the other hand, she said, ''With my medical issues, to get with another insurer pre-Obamacare would have been really hard. So even though I'm bouncing and bouncing around, in some respects the current situation is so much better.''
If Ms. Stuart has a Zen-like approach to the shop-and-switch routine, Ramon Cinco, a middle school teacher in Houston, said he is approaching it ''in panic mode.'' He is switching plans not to get a better deal, but because his current plan with Cigna, which allows his family to see any doctor without a referral, is being discontinued.
Mr. Cinco, 43, switched to Cigna this year after being frustrated with his 2014 plan from Aetna, which he said had too narrow a provider network to be useful. Now, he said, he is likely to switch back to Aetna for 2016, to a plan that seems to have a narrower network of hospitals than he has access to now.
''I wasn't expecting to make a switch for 2016,'' Mr. Cinco said. ''I'm very happy and pleased with my plan, and this came as a big shock.''
As for Ms. Galen, her insurer, LifeWise, is discontinuing her current plan and offering her a similar one with premiums that are 38 percent higher over all. She will get a bigger subsidy next year because of rising rates in her state, so her share of the premium would increase by only $27 a month. But she would also face higher out-of-pocket costs for visiting the doctor, and a higher out-of-pocket limit. And the new plan does not appear to cover her current doctors, she said.
That leaves her with more than a dozen choices from six insurers, which she has begun researching. She wants to make sure she can stick with the dermatologist she has been visiting since her skin cancer diagnosis.
''It's a constant, background nagging feeling of a chore undone,'' she wrote in an email last week. ''And still, it's a huge improvement over the old days! I didn't have to shop at all then; I was stuck with the same rip-off, narrow policy.''
URL: http://www.nytimes.com/2015/11/19/us/shopping-for-health-insurance-is-new-seasonal-stress-for-many.html
LOAD-DATE: November 19, 2015
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GRAPHIC: PHOTOS: ''Every year I feel like I'm starting all over again, and I just dread it,'' said Gail Galen, above, who is comparison shopping for health insurance. (PHOTOGRAPH BY AMANDA LUCIER FOR THE NEW YORK TIMES) (A19)
Insurance options available under Covered California were on view in San Francisco as enrollment reopened on Nov. 1. (PHOTOGRAPH BY JIM WILSON/THE NEW YORK TIMES) (A23)
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The New York Times Blogs
(You're the Boss)
September 18, 2012 Tuesday
A Business Owner Expects the Worst From Health Insurance Overhaul
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1427 words
HIGHLIGHT: Ultimately, Kurt Summers says, the reaction of many small-business owners to the health care overhaul comes down to fear: "I'm sitting at my desk with payroll and expenses wondering, 'What are my customers thinking?'"
The Supreme Court decision upholding most of the Affordable Care Act came as a blow to Kurt Summers, a small-business owner in Austin, Tex. Soon after the decision was announced, he warned his fellow citizens, through the auspices of The Washington Post, that unless "we elect officials to both Congress and the White House who understand the importance of small business and who will return some sanity to Washington" - and repeal the health law - he will most likely have to postpone his considerable ambitions for his company.
In the short-term, today's ruling will force me to pause and rethink my immediate hiring, acquisition and expansion plans. In order to plan ahead, I need to know what future costs and regulations I will be facing. With the law intact, I expect the cost of doing business to increase and new regulations to be delivered by a federal government that doesn't appreciate the daily challenges of running a business.
Like many small companies, our business is largely dependent on the prosperity of larger business; if the economy begins to fail, and if our business customers suffer as a result of this law, the ripple effect will force us to hunker down and perhaps even to let people go.
In our first two profiles of business owners struggling with health care decisions, those owners did not have such strong feelings about the Affordable Care Act - they had hoped they would benefit from it, but they didn't know much about it. Mr. Summers, our third profile, is obviously in a different situation, and we wanted to understand why.
Mr. Summers is a board member for the National Federation of Independent Business, which brought the lawsuit that the Supreme Court decided. He said he originally wrote his article at the behest of the group, which placed it at The Washington Post. Because the N.F.I.B. wanted to distribute its views the moment the Supreme Court spoke, Mr. Summers also prepared reactions to be published in the event of a split verdict or a decision to strike down the whole law.
As it happens, Mr. Summers owns two businesses. Austin Generator Service, a business that his father started in 1978, sells and maintains back-up generators to institutions like hospitals, government offices and high-rise residential buildings. Several years ago, Mr. Summers opened a side business that rents equipment for testing generators and other power equipment. It is called Loadbanks of America, and it has since become his engine of growth. Together the two companies employ 24 people, he said, up from 14 or 15 in 2008. So far this year, he has hired six new people, with plans to hire at least five more next year.
Mr. Summers offers his employees two insurance plans. Most of them subscribe to a major medical policy with a $3,000 deductible. "When you make the deductible, it's a hundred percent paid up to - I guess there's no limit on it now under the new health care law," he said, alluding to a provision, frequently mentioned by Democrats, that eliminates lifetime caps on benefits. (Annual limits on benefits are banned beginning 2014.) There are, however, co-payments for prescription drugs and doctor visits. The insurance is through United Healthcare, and Mr. Summers said he was satisfied with the choice of doctors. This year, Mr. Summers added a similar plan, but with a $4,000 deductible and a health savings account. He does not offer family coverage.
Whatever its limitations, the insurance Mr. Summers provides has gotten more expensive every year. The company currently pays about 90 percent of the premium cost, and "we've increased that contribution every year to cover most of the cost increases that we've seen over the last three years," he said. This year the company is paying about $3,360 per employee. Still, that would make this a relatively inexpensive plan, to judge by the most recent Kaiser Family Foundation survey of employer-sponsored health care, which reports that the average high-deductible plan in the South cost $4,862 in 2012.
But at one point Mr. Summers and his father actually dropped health insurance, because "the premiums exceeded our profits." Five or six years ago, about the time he got into the load bank business, Mr. Summers concluded that he needed to cover himself and his employees, not only to protect the company should he need medical care but also to lure the talent needed to expand.
And he has big plans for the load bank business. His two companies have already outgrown a 5,000-square-foot storage building bought in 2010; in three years, he'd like to build a 20,000-square-foot facility. He would also like to establish branch offices and supply depots in four to six major cities around the country and hire people to staff them. "Assuming the economy doesn't tank, and we don't put the brakes on, we do anticipate being in the 50- to 100-employee range in the next three to five years," he said. The total investment over five years, in land, people, and inventory could range from $5 million to $10 million.
In his commentary, Mr. Summers wrote that he expected "the cost of doing business to increase," but in conversation he was reluctant to be pinned down on the new costs he'd face. He said his insurance agent had told him that the consumer protections in the law - such as removing those caps on reimbursed medical expenses - were at least partly responsible for his higher insurance premiums. ("You cannot provide free services and not pay for it," he said.) But he also acknowledged that it was difficult to gauge the law's direct effects on his business two years before its main provisions would take effect.
Mr. Summers was more comfortable discussing the health care law's implications for the broader economy than the direct effect on his own business. We talked at length about why he fears his customers could retrench in the wake of the law's execution - and how his suppliers might pass on their increased costs to him, raising his costs as his revenue is squeezed. But it turns out that in a long conversation, Mr. Summers's thinking about the law and its effects is a bit more nuanced. He deployed many ifs and coulds. When pressed to explain why he presumed business - that of his customers and his suppliers - would react so negatively to the health care law, he tempered his pessimism.
"I hope I'm not saying that I'm presuming that is going to happen," he said. "I think it could happen, and by nature of that possibility, I simply have to be cautious." Mr. Summers also said that he would be closely monitoring the economy and customer demand irrespective of the health care law's fate, and he would adjust his plans as circumstances warranted.
The Agenda suggested that his customers and suppliers were unlikely to be any better than he at predicting how the law might affect their companies. He conceded this, and a few minutes later offered an explanation for what seems to be a pervasive sense of gloom in the small-business economy.
"When you talk about an economy that's sluggish," he said, "you're really talking about people keeping their money, people not spending their dollars. And it's been proven over and over again that the reason people don't spend their dollars is an emotional decision - it's fear.
"We could look at this very practically and with statistics and facts, but even if we could prove that the impact of the law was minimal, the emotion of the impact is still there. And what's fueling that emotion? Well, maybe it's misinformation, but maybe it's also just plain and simple uncertainty. Maybe it's the reality that I'm sitting at my desk with payroll and expenses wondering, 'What are my customers thinking?'"
The elements of the law intended to help small businesses did not impress Mr. Summers. The wages he pays are too high to qualify for the small-business health tax credit. His firm did receive a small rebate on its insurance premiums made possible by the law, but Mr. Summers dismissed the check as "something stupid" -- less than $200.
"It just created another administrative task for my people," he said. "It was ridiculous."
As always, we'd like to hear from you. If you have an interesting story to tell about how you provide health care for your employees, please drop us a line.
Small Business Health Insurance: Costs Still Going Up
The Affordable Care Act Rebate Checks Are in the Mail: Now What?
Having Lost the Health Care Battle, the N.F.I.B. Readies for a Long War
A Small Restaurant Gets a Big Increase in Health Premiums - and Misses the Tax Credit
How Small Businesses Are Coping With Health Insurance
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The New York Times Blogs
(Economix)
December 20, 2013 Friday
What Stronger Health Spending Growth Means for Obama
BYLINE: CATHERINE RAMPELL
SECTION: BUSINESS; economy
LENGTH: 306 words
HIGHLIGHT: The steeper increase in medical spending shown in the revision of third-quarter economic output is a double-edged sword for the White House.
Gross domestic product growth was much faster than previously estimated in the third quarter, partly because health care spending was revised sharply upward. Consumer spending on health care services grew at an annual pace of 2.7 percent last quarter, instead of 0.9 percent, as the Commerce Department had previously reported.
This news represents a double-edged sword for the White House.
On the one hand, the Obama administration has been promoting evidence that health care spending has been slowing, a fact it has attributed in part to the Affordable Care Act (which is, of course, debatable). Friday's data release complicates that narrative a bit.
"It's still the case that both nominal and real health care spending has generally been slowing, but the slowing isn't quite as pronounced after today's revision," said Michael Feroli, chief United States economist for JPMorgan Chase.
But on the other hand, greater consumer spending of any kind can contribute to faster economic growth, which the United States desperately needs right now. The administration would probably prefer that consumers devote more spending to other goods and services (like clothing or restaurants) rather than health care, but perhaps it will take what it can get.
In its public statements, the White House has also emphasized the decline in growth of health care prices, not just health care spending. The chart below shows the latest trends in health care costs, as measured by the medical care component of the consumer price index, versus the overall consumer price index. As you can see, health care price inflation has indeed fallen over time.
National Health Costs vs. Your Health Costs
Breaking Out of a Cramped Economic Policy Debate
Health Care as an Economic Stabilizer
Health Care Prices Move to Center Stage
Conflicting Pressures on Demand for Doctors
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The New York Times
October 26, 2015 Monday
Late Edition - Final
Free Mitt Romney!
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 21
LENGTH: 837 words
Sometimes I find myself feeling sorry for Mitt Romney. No, seriously. In another time and place, he might have been respected as an effective technocrat -- a smart guy valued (although probably not loved) for his ability to get things done. In fact, that's kind of how it worked when he was governor of Massachusetts, a decade ago.
But now it's 2015 in America, and Mr. Romney's party doesn't want people who get things done. On the contrary, it actively hates government programs that improve American lives, especially if they help Those People. And this means that Mr. Romney can't celebrate his signature achievement in public life, the Massachusetts health reform that served as a template for Obamacare.
This has to hurt. Indeed, a few days ago Mr. Romney couldn't help himself: he boasted to the Boston Globe that ''Without Romneycare, we wouldn't have had Obamacare'' and that as a result ''a lot of people wouldn't have health insurance.'' And it's true!
But such truths aren't welcome in the G.O.P. Ben Carson, who is leading the latest polls of Iowa Republicans, has declared that Obamacare is the worst thing to happen to America since slavery; 81 percent of likely Republican caucus-goers say that this statement makes him more attractive as a candidate.
Not surprisingly, then, Mr. Romney quickly tried to walk his comments back, claiming that Obamacare is very different from Romneycare, which it isn't, and that it has failed.
But you know, it hasn't. On the contrary, the Affordable Care Act has been a remarkable success, especially considering the scorched-earth opposition it has faced.
First of all, a lot of people -- around 16 million, the administration estimates, a picture confirmed by independent sources -- do indeed have health insurance who otherwise wouldn't. Millions more would be insured if Republican-controlled states weren't refusing to expand Medicaid (even though the federal government would pay the costs) and generally trying to obstruct the program.
How good is the insurance thus obtained? Not perfect: despite subsidies, policies are still hard for some to afford, and deductibles and co-pays can be onerous. But most people enrolled under Obamacare report high satisfaction with their coverage, which is hugely better than simply not being uninsured. And may I inject a personal note? If truth be told, I live in a pretty rarefied, upper-middle-class-and-above milieu -- yet even so I know several people for whom the Affordable Care Act has been more or less literally a lifesaver. This is, as Joe Biden didn't quite say, a really big deal.
Oh, and have you noticed how those ads featuring people supposedly hurt by Obamacare have disappeared? That's because none of their stories held up.
What's more, the big Biden deal has come in below budget. Insurance premiums in Obamacare's first two years were well below predictions. It looks as if there will be a partial rebound in 2016, but it's still cheaper than expected. And over all, health care spending has slowed dramatically.
Meanwhile, none of the bad things that were supposed to happen have. Employment growth since the ''job-killing'' law went into effect has been faster than at any time since the 1990s. Employers have not, in fact, eliminated full-time jobs to avoid the act's provisions. And the budget deficit keeps falling.
In short, President Obama, Nancy Pelosi and Harry Reid, who pushed the Affordable Care Act through despite total opposition from the G.O.P., have a lot to be proud of. And so does Mr. Romney, who helped lay the foundation. Instead, however, he's trashing the best thing he's ever done.
You have to wonder: Does Mr. Romney really think that his party would look more favorably on Obamacare if it worked even better than it has, if it cost no money at all? If so, he's delusional. After all, the great majority of Republican-controlled states have turned down free money, refusing to let the federal government expand Medicaid (and in so doing pump money into their economies.)
The point is that from the point of view of the Republican base, covering the uninsured, or helping the unlucky in general, isn't a feature, it's a bug. It's not about how much it costs in taxpayer funds or economic impact: the base is actually willing to lose money in order to perpetuate suffering.
And a movement with those values has no use for technocrats. Ask Ben Bernanke, who has given up on a party in thrall to the ''know-nothingism of the far right.''
Maybe Mr. Romney still imagines that a desperate party will call on him to save it from Donald Trump. Or maybe he just can't bring himself to admit that he picked the wrong group of people to hang out with. Either way, one hopes for his sake that he eventually gives up his illusions. Trust me, Mitt: it will be a liberating experience.
Read Paul Krugman's blog, The Conscience of a Liberal, and follow him on Twitter.
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URL: http://www.nytimes.com/2015/10/26/opinion/free-mitt-romney.html
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The New York Times
November 17, 2013 Sunday
Correction Appended
Late Edition - Final
Tennessee Governor Hesitates on Medicaid Expansion, Frustrating Many
BYLINE: By RICK LYMAN
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 1130 words
NASHVILLE -- Gov. Bill Haslam of Tennessee describes it as ''trying to thread a needle from 80 yards.''
Mr. Haslam is only the latest Republican tailor trying to figure out whether to expand the state's Medicaid rolls as prescribed by President Obama's Affordable Care Act. In his case, it involves trying -- so far unsuccessfully -- to balance some sharply conflicting concerns: struggling hospitals, local business groups, dwindling state resources and fierce conservative opposition to the new health care law.
And it has left him hanging out there, with no resolution in sight, while almost every other state has made a decision, and with many of his impatient constituents wondering how long it is going to take.
''Sometimes you've got to make a tough call,'' said Craig Fitzhugh, the State House Democratic minority leader, who is pushing for expansion. ''It's time to say yes or no. I don't want to get morbid or dramatic about this thing, but it's lives we're talking about here. It's human beings.''
Rick Perry of Texas and Bobby Jindal of Louisiana, among many other Republican governors, have flatly rejected the expansion, even though it would provide billions of federal dollars to their states. Gov. Jan Brewer of Arizona and Gov. Rick Snyder of Michigan are among a small number who decided to accept it, coming under intense criticism from conservatives as a result. Gov. John R. Kasich had to do an end run around his own Republican-controlled Legislature to make it happen in Ohio.
But Mr. Haslam, who had once promised a decision by summer's end, is still trying to negotiate a new plan of his own with federal officials, hoping it will satisfy the competing constituencies. It would involve using federal money to place many of the state's poor on the federal health care exchange created by the act, rather than on Medicaid. But so far he has not persuaded federal officials, who have asked for more details, and said he expected no quick resolution.
Although he is not required to do so, Mr. Haslam has also promised not to enact anything without the approval of the Legislature, whose Republican majority, he said, was dead set against an expansion of Medicaid. Support for his alternative plan seems uncertain at best.
''We don't want to expand a system that's not doing a good job controlling costs,'' the governor said, karate-chopping the air during an interview in his modest Statehouse office. ''We want to end up with something that's not just Medicaid with lipstick on it.''
Though Mr. Haslam has said he felt under no time pressure, the state faces a Jan. 1 deadline to qualify for the first $300 million in Medicaid money for the coming year. The Tennessee Hospital Association, the state Chamber of Commerce and Democrats say Mr. Haslam cannot afford to wait much longer.
The National Conference of State Legislatures says that as of this month, 21 states, all of them with Republican governors or Republican-dominated legislatures, have announced that they would not expand Medicaid, while 27 others, plus the District of Columbia, have already approved an expansion or indicated that they would do so. The election this month of Terry McAuliffe, a Democrat and a supporter of the health care act, as governor of Virginia makes it likely that the state will join the expanders.
That leaves just Tennessee and Pennsylvania, where Gov. Tom Corbett has also asked the Obama administration for permission to use federal funds to buy private health insurance for the uninsured poor, on the fence.
A son of the Knoxville, Tenn., founder of Pilot Flying J, the nation's largest chain of truck stops and travel centers, Mr. Haslam remains a popular figure in his state. A May poll by Vanderbilt University's Center for the Study of Democratic Institutions showed him with a 63 percent approval rating. The same poll, however, found that 60 percent of respondents favored the expansion of Medicaid in the state.
Mr. Haslam, 55, ran for mayor of Knoxville in 2003 as a pro-business conservative, and was re-elected in 2007 with 87 percent of the vote. In 2010, he ran for governor, winning with 65 percent of the vote. He is up for re-election next year and is a prohibitive favorite, with nary a primary challenger in sight and no strong Democratic challenger yet, either.
In Tennessee, opposition to expanding Medicaid has come largely from Republican officeholders and conservative groups. Arrayed on the other side are the Tennessee Hospital Association and other medical groups, the Tennessee Chamber of Commerce and Industry and local chambers across the state, several antipoverty organizations and the Democratic opposition.
Recent layoffs at a few Tennessee hospitals have focused attention on their plight -- and complicated Mr. Haslam's decision.
David McClure, senior vice president for finance at the state hospital association, said that failing to expand Medicaid would have a devastating effect on the state's 165 hospitals, leading to layoffs and the closing of some facilities.
''In every community that has a hospital, we are typically the biggest or one of the biggest employers,'' Mr. McClure said. ''I don't want to be Chicken Little and say the sky is falling, but there will be some hospitals that will close.''
Since hospitals are required to treat patients who show up in their emergency rooms, whether or not they can pay, hospital officials had hoped that adding more poor people to Medicaid rolls would absorb some of those costs, Mr. McClure said.
Without an expansion of Medicaid, hundreds of thousands of Tennessee residents would fall into a gap, making too little money to get subsidized health coverage under the act and too much to qualify for Medicaid. The authors of the Affordable Care Act had assumed that states would expand their Medicaid rolls -- which they had been required to do until the Supreme Court struck down that provision -- providing coverage for these working poor families who fell into the gap.
The hospital association estimates that 400,000 Tennesseans fall into that gap. Other estimates are somewhat lower.
Deepening the angst over this decision is the state's own history with managed health care. Tennessee's homegrown health care system, TennCare, went through a wrenching downsizing in 2005, when the program was totally state sponsored. More than 170,000 people had to be thrown off the TennCare rolls.
Even though the federal government is promising to pay 100 percent of the new Medicaid costs for the first three years and most of the costs after that, Mr. Haslam said he was worried that later administrations might renege on that promise.
''If at some point we're going to have to cut people off the rolls,'' he said, ''I'm not sure we'd want to go through that again. Our history makes us a little wary.''
URL: http://www.nytimes.com/2013/11/17/us/politics/tennessee-governor-hesitates-on-medicaid-expansion-frustrating-many.html
LOAD-DATE: November 24, 2013
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CORRECTION-DATE: November 24, 2013
CORRECTION: An article last Sunday about the Tennessee governor's hesitation over expanding the state's Medicaid rolls described incorrectly a health insurance gap in the state that would occur without the expansion. The gap would include people who make too little money to get subsidized health coverage under the Affordable Care Act and too much to qualify for Medicaid -- not too much for a subsidy and too little for Medicaid.
GRAPHIC: PHOTOS: Gov. Bill Haslam, above, a Republican, is trying to balance conflicting concerns in deciding whether to expand Medicaid in Tennessee. But State Representative Craig Fitzhugh, left, said it was time for him ''to say yes or no.'' (PHOTOGRAPHS BY RICK DIAMOND/GETTY IMAGES FOR GJ MEMORIAL
CHRISTOPHER BERKEY FOR THE NEW YORK TIMES)
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The New York Times
October 30, 2013 Wednesday
The New York Times on the Web
Obama Official Apologizes for Balky Insurance Website
BYLINE: By ROBERT PEAR
SECTION: Section ; Column 0; National Desk; Pg.
LENGTH: 852 words
WASHINGTON -- Marilyn B. Tavenner, the official in charge of President Obama's health insurance marketplace, apologized on Tuesday to millions of Americans who have been frustrated in trying to buy insurance under the new health care law.
''I want to apologize to you that the website is not working as well as it should,'' Ms. Tavenner said, in remarks addressed to the public during testimony before the House Ways Means Committee.
Ms. Tavenner, the administrator of the federal Centers for Medicare and Medicaid Services, said that ''nearly 700,000 applications have been submitted to the federal and state marketplaces'' in the last four weeks.
But she repeatedly refused to say how many of those people had actually enrolled in health insurance plans since the federal and state marketplaces, or exchanges, opened on Oct. 1.
''That number will not be available until mid-November,'' Ms. Tavenner said. ''We expect the initial number to be small.''
The chairman of the Ways and Means Committee, Representative Dave Camp, Republican of Michigan, said that at least 146,000 Michigan residents had recently received notices that their current insurance policies would be canceled because the coverage did not meet requirements of the new health care law.
''In fact,'' Mr. Camp said, ''based on what little information the administration has disclosed, it turns out that more people have received cancellation notices for their health care plans this month than have enrolled in the exchanges.''
Ms. Tavenner said that existing insurance policies were, in many cases, inferior to the new policies they could get. In compliance with the health care law, she said, new policies will provide more benefits and pay a larger share of medical costs than many existing policies.
Representative Kevin Brady, Republican of Texas, asked Ms. Tavenner what she would tell people who were losing their current insurance but could not get coverage on the balky federal website.
''My constituents are frightened,'' Mr. Brady said. ''They are being forced out of health care plans they like. The clock is ticking. The federal website is broken. Their health care isn't a glitch.''
Ms. Tavenner said consumers could seek help from a telephone call center established by the government. To enroll, she said, ''there are more methods than just the website.''
Representative John Lewis, Democrat of Georgia, pushed back against Republican attacks on the law and on the administration.
''The Affordable Care Act is working,'' Mr. Lewis said. ''It is making health insurance affordable and accessible to hundreds of thousands of citizens who never had it before. Health care is a right and not a privilege.''
But while she admitted the failings of the site, Ms. Tavenner tried to hold back a bipartisan clamor for a delay in enforcement of the requirement for most Americans to carry health insurance starting next year.
Lawmakers say it would be unfair to punish Americans for going without insurance if they cannot obtain it on the federal marketplace built by dozens of companies under contract with Ms. Tavenner's agency.
Two of the contractors who worked on the site, testified last week before another congressional committee that the Medicare agency had failed to coordinate the work of dozens of contractors and did not begin ''end-to-end testing'' of the system as a whole until two weeks before it opened to the public on Oct. 1. The tests, they said, revealed flaws in the software and suggested that the site could not handle large numbers of users trying to log on at the same time.
Ms. Tavenner -- like her boss, Kathleen Sebelius, the secretary of health and human services, and her deputy, Gary M. Cohen -- repeatedly assured Congress in the last year that the federal marketplace and its website would be ready on Oct. 1.
Ms. Tavenner said Tuesday that ''nearly 700,000 applications have been submitted to the federal and state marketplaces'' in the last four weeks.
''This tremendous interest, with over 20 million unique visits to date to HealthCare.gov, confirms that the American people are looking for quality, affordable health coverage,'' said Ms. Tavenner, whose agency insures more than 100 million people through Medicare and Medicaid.
The rocky rollout of the new federal insurance program has irked many consumers, caused some to question the competence of federal officials and created a political crisis for Mr. Obama.
''Some have had trouble creating accounts and logging in to the site,'' Ms. Tavenner said. ''Others have received confusing error messages, or had to wait for slow page loads or forms that failed to respond in a timely fashion.''
But, she said, ''We will address these initial and any ongoing problems, and build a website that fully delivers on the promise of the Affordable Care Act.''
The chairman of the Ways and Means Committee, Representative Dave Camp, Republican of Michigan, said: ''Sooner or later the administration needs to admit the law is unworkable. People don't have access to health plans, they cannot compare coverage options and the true cost is often underreported or completely hidden.''
URL: http://www.nytimes.com/2013/10/30/us/politics/obama-official-points-finger-at-contractors-over-balky-insurance-website.html
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The New York Times Blogs
(You're the Boss)
December 18, 2014 Thursday
As Health Insurance Evolves, Traditional Brokers Claim They Still Have a Role
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1221 words
HIGHLIGHT: “It’s complex picking insurance for yourself and your family,” said a health care policy director for a small-business organization. “It’s even more complex for a business.
Are traditional health insurance brokers - the trusted, chatty advisers who are quick to show up at your door at the hint of a problem - becoming obsolete?
In a recent post, we reported that Zenefits, a software company and online brokerage firm that claims to have automated much of what brokers do, seems to have alarmed enough insurance agents that last month, the insurance commissioner in Utah banned Zenefits from serving as a broker in the state.
Meanwhile, embedded in the Affordable Care Act is the idea that health plans ought to be standardized enough that ordinary people can choose among them on their own. What, then, is left for a broker to do?
Not much, according to Parker Conrad, founder and chief executive of Zenefits, who says his clients lose nothing by signing up with his company.
"The only thing that you give up is that we will not come in person. No golf, no steak dinners," Mr. Conrad said. "We'll run an open enrollment meeting for your employees, but we're going to do that over video. What you get on the other side is that everything moves online, so there's no more paperwork, there's no more faxing; it's all done via the system. Employees can make changes themselves."
Companies with at least 20 employees get a dedicated account manager at Zenefits; smaller businesses don't. When it comes to finding a health plan, Zenefits will quote a price, instantly, for every plan available in the state. "A broker, it's like work for them to go generate quotes," Mr. Conrad said. "So probably, particularly if you're a small company, they're not going to go quote you everything. They're going to go quote you five or six pretty standard options."
But is that winnowing such a bad thing? "If they're providing 150 or 200 quotes, how is a client supposed to sift through all those without the experience of having been down that road? That's where the broker comes in," said Ryan Thorn, an agent in Jordan, Utah, and the president of the National Association of Health Underwriters, a trade association for insurance agents.
Mr. Conrad said that a Zenefits account representative goes through the list over the phone to help the client choose a plan, but Mr. Thorn said that "would take hours and hours, and a client doesn't have that much time." Moreover, he added, "I know which of those carriers are strong right now and which have some glitches or some issues. Each quote has its own unique benefits. There are still some nuances between each plan, that you need people to guide you through."
Mr. Thorn said that he did not oppose Zenefits and that the Utah insurance commissioner, Todd E. Kiser, started his investigation on his own initiative, not at the behest of the industry. There is a place for Zenefits, Mr. Thorn said: "There are probably companies out there that really don't care" about having a personal relationship with a broker. "But what happens when there's a claims issue that they cannot resolve? Is there somebody that they can trust locally to get that issue resolved for them?"
A spokesman for Zenefits said that its customer support agents are trained to help clients with a variety of problems, including disputed claims.
David Chase, health care policy director for the Small Business Majority, an organization that began as an advocate for health care law and now operates outreach programs to small businesses on behalf of several state exchanges, said that businesses trust brokers to make sense of the complexity surrounding health insurance.
"It's complex picking insurance for yourself and your family," Mr. Chase said. "It's even more complex for a business. A business has to take into account its budget, for one thing, you've got to be aware of all the different tax laws when you look at employer coverage, and then you've got to factor in the needs of all your employees and your dependents."
"If you're a small-business owner, you know how to provide your product or service," he continued. "But when it comes to health insurance, it's a very foreign concept for them. They're out of their element" - while brokers "do this for a living."
The health insurance landscape for small businesses is undeniably changing, in no small part because of the Affordable Care Act. Most obviously, the small-business health insurance, or SHOP, exchanges established by the health law could be seen as an effort, or opportunity, to supplant brokers: The exchanges were intended to allow businesses to compare plans from different insurers and then purchase a plan, or several plans. In theory, an exchange makes a broker irrelevant.
But in practice, some of the people who build exchanges have come to see brokers as essential. Mr. Chase said that exchanges had learned from past experience that cutting brokers out of the transaction only made unnecessary enemies. If the exchanges enlist the agents as partners, he said, the agents become "a de facto sales team" for the exchanges. Mr. Chase said that in his group's work for California and other states, "we see brokers as partners in our education efforts."
Alan Cohen, a founder of Liazon, a benefits company, discovered something similar when he began to try to sell businesses on the merits of a private exchange. "It's simply hard to disrupt a relationship that has existed in some way or form for decades," he said. "Every company has always used brokers."
Moreover, he said, clients still want the steak dinner, or at least the attention of somebody local: "It's a personal business, it's a service support business, and you want a broker who if there's a problem will show up in your office today."
Mr. Cohen predicted that Zenefits would struggle as its clients become bigger. "Here's what's going to happen," he said. "Those companies are going to grow up. They're not going to be 30 employees anymore; they're going to be 100 employees and 200 employees, and they're going to need a real consultant."
Mr. Conrad maintained that much of the time that brokers devote to clients today is busywork that his software automates. "People's relationships with their broker, they have a certain amount of value," he said. "And all you have to do is you have to provide value that exceeds the value of that relationship, and they will switch. Our software makes us a better broker."
Ultimately, the fate of brokers will depend on the desires and needs of business owners. "My experience with brokers is that they don't have to understand anything," said Paul Downs, a business owner who contributes to You're The Boss and has written extensively about his difficulties in buying health insurance. "They just have to be smiley, chatty people. They're fun to talk to, they make you comfortable, and then they sell you something. And neither of us understands what we're buying."
Health insurance, Mr. Downs said, is deliberately, and needlessly, complex. "You're like a cow being herded down a chute at the slaughterhouse," he continued. "You have no place to go. Eventually you realize that you need to buy insurance, and somebody shows up in your office and puts a piece of paper down on your desk for you to sign.
"You can either sign it and move on, or you can torture yourself. And 99 percent of business owners want to get on with making money. They realize that drowning in the details of these transactions doesn't get them anywhere."
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The New York Times
January 31, 2014 Friday
Late Edition - Final
Henry Waxman, Key Democrat and Force for Health Care Law, Is to Retire
BYLINE: By JONATHAN WEISMAN
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 643 words
CAMBRIDGE, Md. -- Representative Henry A. Waxman of California, a diminutive Democratic giant whose 40 years in the House produced some of the most important legislation of the era, announced Thursday that he would retire at the end of the year.
Mr. Waxman, 74, joins a growing list of House members who are calling it quits, many in disappointment over the partisanship and ineffectiveness of a Congress that may end up as the least productive in history.
''It's been frustrating because of the extremism of Tea Party Republicans,'' Mr. Waxman said in an interview on Wednesday. ''Nothing seems to be happening.''
The frustration is felt on both sides. More than 30 House members have announced they will retire, resign or run for other offices this year, including stalwarts like George Miller, Democrat of California; Tom Latham, Republican of Iowa; Frank R. Wolf, Republican of Virginia; and Howard P. McKeon of California, chairman of the Armed Services Committee.
Mr. Waxman's departure after 20 terms in the House will be particularly poignant. One of his most notable accomplishments, the Affordable Care Act, which he was instrumental in writing, is shaping up as the centerpiece of campaigns all over the country, not as a triumph but as a Republican cudgel. And the expansion of Medicaid that he has championed has been challenged in a number of states run by Republican governors.
The sprawling bill to combat climate change that he wrote was passed by the House in 2009 but died in the Senate, and President Obama has given up on efforts to push it through. Mr. Waxman has also spent years trying to strengthen the powers of the Food and Drug Administration and the Environmental Protection Agency, but those efforts are under fire from the Republicans who control the House.
Still, Mr. Waxman will leave behind a legacy of entrenched accomplishments, including the Children's Health Insurance Program, which extends coverage to millions of low-income children; anti-tobacco, food safety and food-labeling laws; and the Ryan White Care Act, which allocates billions of dollars in federal money for the treatment of H.I.V. and AIDS.
He is also credited with laying the foundation for many of the executive actions that Mr. Obama, during his State of the Union address on Tuesday, pledged to pursue.
One involves the Clean Air Act, which Mr. Waxman helped write and which gives the Environmental Protection Agency the authority it is now exercising to regulate power plant emissions of greenhouse gases. Mr. Waxman saw to it that the bill would allow the president, on his own, to order improvements in automobile fuel efficiency and other energy saving efforts.
Mr. Waxman -- whose 33rd Congressional District hugs the Southern California coast and includes Malibu, Beverly Hills and Santa Monica -- has long been a House leader.
For five years beginning in 1979, he was chairman of the Energy and Commerce subcommittee on health and the environment. He often butted heads on environmental issues with the chairman of the full committee, John D. Dingell of Michigan, who at 6 foot 3 is 10 inches taller than Mr. Waxman.
In 2008, Mr. Waxman defeated Mr. Dingell in a secret House vote to become chairman of the full committee.
After the Republicans regained control of the House two years later, he became the committee's ranking Democratic member.
Earlier, when he served on the House Oversight and Government Reform Committee, Mr. Waxman conducted high-profile investigations of Wall Street, Major League Baseball, Pentagon contractors and the tobacco industry.
He has been unapologetic about the health care law during its troubled rollout in the fall, and he said that he was confident it would survive and that its use as a political weapon would diminish.
''I'm proud of the Affordable Care Act,'' he said. ''I think it's a terrific piece of legislation.''
URL: http://www.nytimes.com/2014/01/31/us/politics/henry-a-waxman-a-house-democratic-fixture-will-retire.html
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GRAPHIC: PHOTO: Representative Henry A. Waxman in 2012. He said Tea Party Republicans blocked progress. (PHOTOGRAPH BY JOSHUA ROBERTS/REUTERS)
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The New York Times
January 30, 2012 Monday
Late Edition - Final
Health Costs, Regardless of Your Politics
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 22
LENGTH: 792 words
To the Editor:
Re ''What We Give Up for Health Care,'' by Ezekiel J. Emanuel (Sunday Review, Jan. 22):
Dr. Emanuel is correct that no Americans, including liberals, can ignore escalating health care costs. Unfortunately, this is exactly what he and the rest of the Obama administration did in passing the Affordable Care Act.
To obtain the cooperation of important stakeholders -- the American Medical Association, the American Hospital Association and major pharmaceutical companies -- in achieving the laudable goal of expanding coverage, our dysfunctional, inefficient and exceedingly expensive system was left intact.
Now we must do the heavy lifting of actually fixing America's health care system by carrying out structural improvements that will, by their very nature, reduce the incomes of many powerful health care constituencies. This reform effort is the struggle upon which history will judge President Obama's health care initiatives, for, if we fail, America will not only be unable to afford the expanded coverage of the new health care law, but we will also be unable to continue Medicare or Medicaid as we know them.
JAMES B. RICKERT Bloomington, Ind., Jan. 23, 2012
The writer is an orthopedic surgeon.
To the Editor:
Ezekiel J. Emanuel chooses to assign liberals with controlling costs in health care, when he should be waving his finger at the health care sector. When ''skyrocketed'' health care costs come up, profit never makes it into the discussion or calculations.
Dr. Emanuel should remember, too, that many liberals wanted the cost-saving, improved Medicare-for-all system to be included in Senator Max Baucus's committee hearings. Sadly, the cabal made sure that its proponents got no seat at the table.
H.R. 676, the Expanded and Improved Medicare for All Act, would have cut out unnecessary administrative costs, given Americans real choice in their health care, and dissolved the employment-benefits contract that keeps us an indentured labor force. These are factors that both liberals and conservatives should be able to support.
BARBARA COMMINS San Francisco, Jan. 22, 2012
The writer is a registered nurse.
To the Editor:
Ezekiel J. Emanuel suggests that liberals ''ignore costs.'' He doesn't seem to recognize that many conservatives oppose the payment reform proposals in the Affordable Care Act. Remember the outcry about ''death panels''?
Moreover, it should not be a given that insurers should continue to consume a large fraction of the health care dollar.
There are many good options for payment reform not included in the health care law. We need a wider discussion on how care is paid for, and how everyone can have access to care in a way that is more efficient, safer and better.
Our government should not write off the possibility of single-payer (which it has so far, largely because of conservative opposition). Those are liberal ideas, and they do not mean that costs should be ignored.
BRUCE L. WILDER Pittsburgh, Jan. 22, 2012
The writer is a neurosurgeon and a lawyer.
To the Editor:
When it comes to health services, liberals care about costs but also have a sense of history. In the 1960s, the United States had arguably the best health care in the world despite the usual suspects abusing the system. Then there was the steady power grab by the health maintenance organizations and pharmaceuticals that turned health care into an industry rather than a human right.
Eliminate the greed-driven, corrupt and often incompetent middlemen, and costs will plummet.
CAROL SANJOUR Brooklyn, Jan. 22, 2012
The writer is a clinical psychologist.
To the Editor:
Ezekiel J. Emanuel cites many adverse economic effects of American health care but exhibits a blind spot for a potentially catastrophic hazard of reform. Health care is enormously labor-intensive. A reform that reduces health care's percentage of gross domestic product to Germany's 10.5 percent or Britain's 8.7 percent from the American 17 percent inevitably reduces employment by as much or more.
Many hundreds of thousands of hospital nurses, technologists, administrators, secretaries and doctors become unemployed or must find new positions. One does not simply free 6.5 to 8.3 percent of G.D.P. for other purposes; it disappears.
Moreover, those losing jobs cannot simply be reprogrammed instantly to support education or some other virtuous purpose; their skills are obsolete.
Thus, the demand for government programs to support the unemployed and prematurely retired will increase enormously. If advocates for health care reform continue to ignore this issue, any success they have will only undermine our economy in the future.
NATHANIEL REICHEK Roslyn, N.Y., Jan. 22, 2012
The writer is a professor of medicine and biomedical engineering at Stony Brook University.
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The New York Times
April 4, 2014 Friday
Late Edition - Final
Rube Goldberg Survives
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 27
LENGTH: 798 words
Holy seven million, Batman! The Affordable Care Act, a k a Obamacare, has made a stunning comeback from its shambolic start. As the March 31 deadline for 2014 coverage approached, there was a surge in applications at the ''exchanges'' -- the special insurance marketplaces the law set up. And the original target of seven million signups, widely dismissed as unattainable, has been surpassed.
But what does it mean? That depends on whether you ask the law's opponents or its supporters. You see, the opponents think that it means a lot, while the law's supporters are being very cautious. And, in this one case, the enemies of health reform are right. This is a very big deal indeed.
Of course, you don't find many Obamacare opponents admitting outright that 7.1 million and counting signups is a huge victory for reform. But their reaction to the results -- It's a fraud! They're cooking the books! -- tells the tale. Conservative thinking and Republican political strategy were based entirely on the assumption that it would always be October, that Obamacare's rollout would be an unremitting tale of disaster. They have no idea what to do now that it's turning into a success story.
So why are many reform supporters being diffident, telling us not to read too much into the figures? Well, at a technical level they're right: The precise number of signups doesn't matter much for the functioning of the law, and there may still be many problems despite the March surge. But I'd argue that they're missing the forest for the trees.
The crucial thing to understand about the Affordable Care Act is that it's a Rube Goldberg device, a complicated way to do something inherently simple. The biggest risk to reform has always been that the scheme would founder on its complexity. And now we know that this won't happen.
Remember, giving everyone health insurance doesn't have to be hard; you can just do it with a government-run program. Not only do many other advanced countries have ''single-payer,'' government-provided health insurance, but we ourselves have such a program -- Medicare -- for older Americans. If it had been politically possible, extending Medicare to everyone would have been technically easy.
But it wasn't politically possible, for a couple of reasons. One was the power of the insurance industry, which couldn't be cut out of the loop if you wanted health reform this decade. Another was the fact that the 170 million Americans receiving health insurance through employers are generally satisfied with their coverage, and any plan replacing that coverage with something new and unknown was a nonstarter.
So health reform had to be run largely through private insurers, and be an add-on to the existing system rather than a complete replacement. And, as a result, it had to be somewhat complex.
Now, the complexity shouldn't be exaggerated: The basics of reform only take a few minutes to explain. And it has to be as complicated as it is. There's a reason Republicans keep defaulting on their promise to propose an alternative to the Affordable Care Act: All the main elements of Obamacare, including the subsidies and the much-attacked individual mandate, are essential if you want to cover the uninsured.
Nonetheless, the Obama administration created a system in which people don't simply receive a letter from the federal government saying ''Congratulations, you are now covered.'' Instead, people must go online or make a phone call and choose from a number of options, in which the cost of insurance depends on a calculation that includes varying subsidies, and so on. It's a system in which many things can go wrong; the nightmare scenario has always been that conservatives would seize on technical problems to discredit health reform as a whole. And last fall that nightmare seemed to be coming true.
But the nightmare is over. It has long been clear, to anyone willing to study the issue, that the overall structure of Obamacare made sense given the political constraints. Now we know that the technical details can be managed, too. This thing is going to work.
And, yes, it's also a big political victory for Democrats. They can point to a system that is already providing vital aid to millions of Americans, and Republicans -- who were planning to run against a debacle -- have nothing to offer in response. And I mean nothing. So far, not one of the supposed Obamacare horror stories featured in attack ads has stood up to scrutiny.
So my advice to reform supporters is, go ahead and celebrate. Oh, and feel free to ridicule right-wingers who confidently predicted doom.
Clearly, there's a lot of work ahead, and we can count on the news media to play up every hitch and glitch as if it were an existential disaster. But Rube Goldberg has survived; health reform has won.
URL: http://www.nytimes.com/2014/04/04/opinion/krugman-rube-goldberg-survives.html
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The New York Times
March 21, 2017 Tuesday
Late Edition - Final
Going Upstate to Lure Votes for Health Bill
BYLINE: By THOMAS KAPLAN and ROBERT PEAR; Jesse McKinley contributed reporting from Albany.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1154 words
WASHINGTON -- House Republican leaders, trying to lock down the votes of wavering upstate New York Republicans, inserted a last-minute special provision in their health care bill that would shift Medicaid costs from New York's counties to its state government.
The move -- one of a number of late changes designed to gain more votes -- would affect New York State only. It could save county governments outside of New York City $2.3 billion a year. But it could shift costs to state taxpayers or deny New York that same total in matching federal aid if the state continues to require those counties to contribute to the cost of Medicaid. Upstate New York Republicans, backed by local government officials, pressed for the measure over the angry opposition of New York's Democratic governor, Andrew M. Cuomo.
''The more we learn about the repeal and replacement for the Affordable Care Act, the sicker New York gets,'' Mr. Cuomo said in a statement Monday night.
Republican leaders were in no position to oppose the demands of back-bench House members as they scrounged for a majority of votes. Democrats used such targeted provisions to push the Affordable Care Act over the finish line in 2009 and 2010 -- to the angry cries of Republicans who accused them of kickbacks and buyoffs.
Republican opponents of President Barack Obama's signature domestic achievement accused Democrats of back-room deal making, rushed legislating and strong-arm partisan tactics, even as the health care bill plodded toward passage over months of deliberation and public debate.
But wheeling and dealing may be what the Republican leaders need to get the health bill through the House as they dash toward a vote as early as Thursday. The House leaders released a set of revisions to the bill late Monday night, including some to speed up the repeal of taxes in the Affordable Care Act.
The newly released set of changes does not directly provide more generous tax credits for older Americans, as many Republicans had been requesting, but it lays the groundwork for the Senate to enhance those tax credits at a later stage in the legislative process.
''With the president's leadership and support for this historic legislation, we are now one step closer to keeping our promise to the American people and ending the Obamacare nightmare,'' the House speaker, Paul D. Ryan, said in a statement.
President Trump and House conservatives already agreed to other changes involving Medicaid, including offering states the option of imposing a work requirement for certain able-bodied beneficiaries. They also agreed to let states choose a lump-sum block grant to fund their Medicaid programs instead of a per-capita allotment originally set in the House bill.
The changes designed to win over conservatives may still not secure the votes of some of the most hard-line among them, including many members of the House Freedom Caucus. But in a big break for Mr. Trump and Mr. Ryan, the group's leader, Representative Mark Meadows of North Carolina, said it would not take a collective position on the bill.
That gave Mr. Trump the power to woo members one by one. The president planned to meet with House Republicans at the Capitol on Tuesday.
But House leaders also faced a problem from the other direction: Some Republicans had misgivings about the House bill not because they viewed it as ''Obamacare Lite,'' but because they worried that it would cause millions of people to lose health insurance or would inflict great harm on their districts.
By offering a provision to please Republicans from New York -- which expanded Medicaid under the Affordable Care Act -- House leaders could stand to secure several needed votes, with little risk of alienating other members.
Representative John J. Faso, Republican of New York, said the state would be provided a substantial period of time to prepare for the change.
''The New York State property tax burden is one of the worst in the country, and Medicaid is part of the reason,'' Mr. Faso said.
Mr. Faso and his fellow Republicans from New York had leverage. Representative Chris Collins, who pushed for the provision with Mr. Faso, noted that House leadership ''was concerned about getting the votes'' to get the health bill passed.
''I suggested we put this in,'' Mr. Collins said, ''and the question that came back was, 'If we do it, can we get the New York votes?''' He said aside from one member, ''the rest of us, kind of as a pack, went to leadership and said, 'Yeah, you get this in here, you've got our votes.'''
Mr. Collins, a former Erie County executive, said he now believed that eight of the nine Republican members of New York's House delegation would vote for the bill. ''If they did not have the New Yorkers, I'm not sure they could get it over the finish line,'' he said.
Mr. Cuomo, who had already warned that the House bill would cause New York to lose billions of dollars, said the change sought by the Republicans would have dire consequences.
''The cut is so severe that the majority of hospitals, nursing homes and assisted living facilities located in upstate New York and on Long Island would be devastated,'' Mr. Cuomo said.
Medicaid, which provides health care to low-income people, is jointly financed by the federal government and the states. New York raises some of its share from counties, which have long chafed under what they view as an ''unfunded mandate'' from Albany.
County property taxes represent only a portion of the overall amount of property taxes that are paid by New Yorkers. A much larger share goes toward schools.
But William Cherry, the Schoharie County treasurer, said upstate counties would be able to make a significant reduction to their property taxes if they did not have to shoulder part of the cost of the state's Medicaid program.
''This would be a huge step and a great benefit to taxpayers,'' said Mr. Cherry, a Republican who is president of the New York State Association of Counties.
The provision being added to the House bill would not apply to New York City, which would continue to foot the bill for its share of Medicaid costs.
Kenneth E. Raske, the president of the Greater New York Hospital Association, said the provision would be harmful to hospitals and Medicaid beneficiaries.
''Rather than providing relief for county taxpayers,'' Mr. Raske said, ''the state would surely respond to the lack of federal revenue through huge spending cuts,'' and those cuts could pose a risk to hospitals and their patients.
Bea Grause, the president of the Healthcare Association of New York State, said the provision being added to the House bill might give ''the appearance of tax relief,'' but would really just amount to shifting costs from counties to the state, while still leaving patients in need of care.
She, too, warned of a devastating effect on hospitals in New York. ''It adds insult to injury,'' she said.
URL: http://www.nytimes.com/2017/03/20/us/politics/house-health-care-new-york-republicans.html
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GRAPHIC: PHOTO: House Speaker Paul D. Ryan, with fellow Republican leaders, speaking about the American Health Care Act last week. A late provision was added to please Republicans from New York. (PHOTOGRAPH BY GABRIELLA DEMCZUK FOR THE NEW YORK TIMES) (A16)
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The New York Times
January 10, 2016 Sunday
Late Edition - Final
Insurers Say Costs Are Climbing as More Enroll Past Health Act Deadline
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 1507 words
WASHINGTON -- Eager to maximize coverage under the Affordable Care Act, the Obama administration has allowed large numbers of people to sign up for insurance after the deadlines in the last two years, destabilizing insurance markets and driving up premiums, health insurance companies say.
The administration has created more than 30 ''special enrollment'' categories and sent emails to millions of Americans last year urging them to see if they might be able to sign up after the annual open enrollment deadline. But, insurers and state officials said, the federal government did little to verify whether late arrivals were eligible.
That has allowed people to wait until they become ill or need medical services to sign up, driving up costs broadly, insurers have told federal health officials.
''Individuals enrolled through special enrollment periods are utilizing up to 55 percent more services than their open enrollment counterparts'' who sign up in the regular period, the Blue Cross and Blue Shield Association, whose local member companies operate in every state, told the administration.
In a notice published recently in the Federal Register, the administration said it had ''heard concerns that these special enrollment periods may be subject to abuse,'' and asked for evidence. The insurance companies obliged.
''Many individuals have no incentive to enroll in coverage during open enrollment, but can wait until they are sick or need services before enrolling and drop coverage immediately after receiving services, making the annual open enrollment period meaningless,'' Steven B. Kelmar, an executive vice president of Aetna, said in a letter to Sylvia Mathews Burwell, the secretary of health and human services.
A quarter of the applications that Aetna received in the health law's public insurance marketplace last year came through special enrollment periods, he said.
Administration officials said they wanted to prevent any misuse or abuse of special enrollment periods, and they are expected to outline their plans this week. But, they said, people must be able to sign up late when they have a legitimate reason. And many have.
Kevin J. Counihan, the chief executive of the federal insurance marketplace, said nearly 950,000 people used special enrollment periods to get coverage through HealthCare.gov from late February to the end of June 2015. That, he said, shows the marketplace is working to meet people's needs.
In a typical email in September, federal officials told consumers: ''You may still be able to get 2015 coverage. Certain life changes like losing your coverage, having a child, turning 26, moving or getting married may qualify you for a special enrollment period. See if you qualify.''
And people have been helped.
''I was terminated from my job in March,'' said Nancy T. Frost, 61, a truck-driving instructor from Farmingdale, Me., who needed insurance after the last open enrollment ended in early 2015. ''All of a sudden, you don't have a job, and you don't have health insurance. I did not know when I would start on a new job, and I did not want to be fined for not having insurance. I was lucky to be able to sign up for affordable care outside the sign-up period, and am very appreciative of it.''
Insurers always knew that consumers would come and go for various reasons, but they have been surprised at the amount of turnover.
''On average,'' Aetna said, ''special enrollment period enrollees stay with us for less than four months, while enrollees who come to us during the annual open enrollment period maintain their coverage on average for eight to nine months.''
Daniel J. Schumacher, the chief financial officer of UnitedHealthcare, the insurance unit of UnitedHealth Group, said more than 20 percent of its marketplace customers signed up after open enrollment ended last year. And they used 20 percent more health care than people who signed up before the deadline, he said.
The National Association of Insurance Commissioners, representing state officials, is troubled by the trend.
''State regulators are concerned that consumers are not required to provide documentation to substantiate their eligibility for a special enrollment period,'' the association said in a letter to the federal Department of Health and Human Services. ''We know of many cases where individuals with serious medical conditions purchased coverage midyear by simply checking the right box or using the right language, and their eligibility was not questioned.''
Such concerns could portend higher insurance rates broadly. In setting current premiums, insurers say, they did not realize how many people would sign up after the deadline and how much care they would use. That information may affect future rates and benefits. Insurers are supposed to file their proposed rates and benefits for 2017 in April and May this year.
Greg Thompson, a spokesman for Health Care Service Corporation, which runs Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas, said one-fourth to one-third of its marketplace customers came in through special enrollment periods. And in their first month of coverage, he said, they were much more likely to generate large claims.
What's more, said Anthony Mader, a vice president of Anthem, another big insurer, ''enrollees coming in through special enrollment periods are more than twice as likely to drop coverage after a short period of time as individuals enrolling during open enrollment.''
''This practice,'' he said, ''is harming the stability of the exchange markets and resulting in higher premiums.''
But like so many aspects of the Affordable Care Act, pain for some is gain for others. Alena and Andrei Dzianisau of Charlotte, N.C., came here from Belarus seven years ago. When they applied for insurance last year, they fell into a gap: They could not qualify for Medicaid because North Carolina has not expanded eligibility. But their income was below the poverty level, so, under federal law, they could not obtain subsidies for private insurance. Later, Mrs. Dzianisau earned additional income as a babysitter, which made them eligible for subsidies, and they signed up in a special enrollment period.
Loss of coverage, such as Medicaid or employer-sponsored insurance, is a common reason for people to seek a special enrollment period. In some cases, insurers and state officials said, consumers lose coverage because they failed to pay premiums, then sign up with the same or a different insurer a few months later during a special enrollment period. Under federal rules, that is not supposed to happen.
The federal government allows people to sign up or switch health plans outside open enrollment for various reasons. Lawyers said it was not easy to find a complete list of the eligibility criteria, which have been set forth in regulations, bulletins, official policy statements, manuals and informal ''guidance documents.'' Some of the reasons are straightforward, like getting married or having a baby.
Others are more complicated and less clear-cut. Consumers may, for example, be eligible for a special enrollment period in ''exceptional circumstances'' and in ''other situations determined appropriate'' by the Centers for Medicare and Medicaid Services. The circumstances may include ''a serious medical condition'' that kept a person from enrolling.
Even companies that strongly support the Affordable Care Act say officials need to do more to check eligibility.
Anthony A. Barrueta, a senior vice president at Kaiser Permanente, a large health plan, said the potential for misuse of special enrollment periods ''poses a significant threat to the affordability of coverage, and to the viability'' of federal and state exchanges.
Consumer advocates said they had not seen evidence of abuse.
''Most consumers are confused by the rules on special enrollment periods and do not understand the system well enough to try to game it,'' said Christine Speidel, a lawyer at Vermont Legal Aid. On the other hand, she said, ''many people feel that insurance is not affordable, even with subsidies, and they will call the marketplace to see if they qualify for insurance when they get sick.''
Moreover, consumer advocates said, the government is partly responsible for the proliferation of special enrollment periods.
In some cases, they said, consumers tried to sign up before the deadline, but were stymied by errors in government computer systems. In other cases, they said, people needed a special enrollment period because they had been improperly dropped from the rolls or left in limbo while trying to resolve questions about their citizenship.
Enroll America, a nonprofit group with close ties to the Obama administration, said the government ''should not tighten eligibility or verification standards in ways that could place an undue burden on consumers.''
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URL: http://www.nytimes.com/2016/01/10/us/politics/insurers-say-costs-are-climbing-as-more-enroll-past-health-act-deadline.html
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(In Practice)
September 27, 2013 Friday
Answers to Some Questions About Health Care Exchanges
BYLINE: Jane Bornemeier
SECTION: US
LENGTH: 293 words
HIGHLIGHT: Your Money columnist Tara Siegel Bernard has answers to your questions about the new health care exchanges opening on Oct. 1.
It's a little like an election: Most people don't focus on it until they prepare to vote. Now that the new health care exchanges are about to open, potential buyers of the new plans are trying to understand the law. Your Money columnist Tara Siegel Bernard has answers to some of the most perplexing questions and is standing by to answer more from readers. You can find her full column here.
Here are a few:
Q. How can I find out if my doctor accepts exchange-based insurance?
A. Many insurance providers' networks of doctors and hospitals will be narrower than typically found in commercial insurance, as my colleague reported earlier this week. Just because your doctor accepts, say, a Blue Cross plan provided by your employer doesn't necessarily mean the doctor will take the same carrier's plan offered on the exchange.
The plans will be required to provide a directory of their providers, so inspect them carefully.
Q. How will I know if my drugs are covered by the plans?
A. The exchanges must include a summary of benefits and coverage for each plan, including information about co-payments for generic, brand-name and specialty drugs. There should also be a Web link to the plan's list of covered drug.
Q. If I have employer-based coverage, can I go to the exchange for coverage?
A. You can, but you probably won't want to. Your employer's plan is usually a better deal. Many employers heavily subsidize your premiums and you can pay for your coverage using pretax dollars, something you can't do if you buy coverage on the exchange.
Polls in Overtime on Affordable Care Act
A Scramble as Day 1 Approaches
Picking a Plan and a Cobra Choice
Online Map Helps New Yorkers Understand Federal Health Law Benefits
One State's Way to Bolster Health Coverage for Poor
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The New York Times
June 10, 2014 Tuesday
Late Edition - Final
For Virginia Democrat, Obama's Still a Positive
BYLINE: By ASHLEY PARKER
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1122 words
ARLINGTON, Va. -- In an election season when many congressional Democrats are avoiding President Obama as if he were a quirky relative at a family reunion, Don Beyer has cast himself as an unrepentant advocate.
A candidate running for the Democratic nomination in Virginia's Eighth Congressional District, which includes the suburbs outside Washington, Mr. Beyer said in a radio ad that the president was ''absolutely right'' about health care, and that is just the start.
''In Congress, I'll fight all efforts to repeal Obamacare, because making sure millions of Americans get affordable health care is the right thing to do,'' he continued.
And his television ads check through a host of progressive positions -- reproductive rights, equal pay, ''common sense'' gun laws and a carbon tax.
The district, one of the shortest commutes to the Capitol of all 435 House seats and packed with government workers and contractors, is one of the relatively few places where the president remains solidly popular. The area helped Mr. Obama become the first Democrat since Lyndon B. Johnson in 1964 to win the state during the 2008 presidential election -- and do it again in 2012, when he won the district with 68 percent of the vote.
In other parts of the country, Democrats are running from the president, eager to distance themselves from the Affordable Care Act and its bungled rollout, much as Republicans tried to separate themselves from President George W. Bush during the midterm elections of his second term, when the disaster of Hurricane Katrina and the unpopular Iraq war loomed large.
Mr. Beyer is decidedly not among them.
''I didn't think about embracing the president,'' said Mr. Beyer, 63, lieutenant governor of Virginia for two terms in the 1990s, who was Mr. Obama's 2008 mid-Atlantic finance chairman and went on to be named ambassador to Switzerland. ''It was more about embracing the ideas.''
But, Mr. Beyer added in an interview, ''I'm not campaigning in southwest Virginia, where it would be much harder.''
A recent Don Beyer for Congress fund-raiser, for instance, had the distinct feel of an Obama reunion tour. A huge enlargement of a front-page image from Nov. 5, 2008 -- the day after Mr. Obama made history -- leaned against a wall. The iconic ''Hope'' poster hung framed above the buffet, with Mr. Obama's visage keeping an eye on platters of greasy fried won tons.
Representative James P. Moran, a Democrat who is retiring, has held the seat -- which includes Arlington and Alexandria -- for over two decades, often winning with more than 60 percent of the vote.
The real election will come in the Democratic primary on Tuesday; the November contest is likely to be a formality. Also on Tuesday, Representative Eric Cantor of Virginia, the House majority leader, and Senator Lindsey Graham of South Carolina are expected to win their Republican primary contests, although they face the opposite problem of Mr. Beyer -- fending off challenges from their party's conservative base.
The Northern Virginia district is ''like Disneyland for progressives,'' said George Burke, the communications director to Representative Gerald E. Connolly, another Virginia Democrat.
Mr. Connolly said the question for the voters would be whom they would like to see as Mr. Moran's successor. ''Do I want maturity in leadership and experience?'' he said. ''Or do I want the fresh face who's untried, but what the heck? And the field offers a little bit of all of that.''
David Wasserman, the House editor for the nonpartisan Cook Political Report, said that the district was one of roughly a dozen where the Democratic nominee is all but guaranteed to win the seat -- and where the candidates are all running to the left. The district is the eighth-most affluent in the nation in terms of median household income, and the third-most educated, according to the Census Bureau.
''Doing anything less than doubling down on Obamacare, supporting gun control and fighting climate change would be suicide in this district,'' Mr. Wasserman said. ''I don't give Don Beyer a profile in courage.''
Mr. Beyer is not even the most liberal candidate in the field, which represents a veritable rainbow of progressivism. Lavern Chatman, who is black, is a former president of the Northern Virginia Urban League and enlisted Oprah Winfrey for a fund-raiser; State Senator Adam P. Ebbin is the first openly gay member of the Virginia legislature; William D. Euille, also black, is the mayor of Alexandria; Patrick A. Hope, a Virginia General Assembly delegate, founded the Virginia Progressive Caucus; and Mark Levine, a talk-show host, is also gay.
But Mr. Beyer, who lost in his 1997 race for governor and owns a chain of Volvo dealerships, has several competitive advantages, notably in name recognition and fund-raising.
At a Memorial Day parade in Falls Church, Mr. Beyer -- clad in cream linen pants and suede Cole Haan bucks (bought by his wife) -- beamed serenely and waved at the crowd, including a significant number of people wearing ''Don Beyer 3K'' T-shirts. More than three decades ago, Mr. Beyer's original Volvo dealership in Falls Church started the ''fun run,'' which drew just 222 runners; now, more than 6,000 show up.
Mr. Beyer said he would love to have the president campaign for him, but was sensitive to the president's unpopularity in much of the country.
''I do think difference is a big part of it,'' he said. ''Not just that the president is African-American, but that I think it's harder for so many people in rural America to identify with an African-American, Kenyan father, Harvard Law School. I mean, he's an incredibly special person, but hardly mainstream.''
Despite Mr. Beyer's enthusiastic embrace of the administration's policies, both he and those who know him say he would more likely be a reach-across-the-aisle moderate legislator. (The Cook Political Report's assessment of the race even notes that some of his previous positions -- his since-reversed 1990s opposition to same-sex marriage, for instance -- would be ''ripe for attack in a Democratic primary,'' though none of his opponents have the resources to mount such a campaign.)
''I would not like to be in a left corner, but rather to make these issues that we in the middle can find ways to move forward on,'' said Mr. Beyer, who cited former Representative Tom Davis and former Senator John W. Warner as two Virginia Republicans he admired, for their willingness to compromise.
And Mr. Davis was quick to note that Mr. Beyer breaks the typical House legislator mold in a variety of ways -- as a former lieutenant governor, ambassador, and as a Democratic car dealer.
''As you know, Republicans don't buy Volvos,'' Mr. Davis said, ''and Republicans don't sell Volvos.''
URL: http://www.nytimes.com/2014/06/10/us/politics/for-virginia-democrat-obamas-still-a-positive.html
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November 19, 2016 Saturday 00:00 EST
The Wreckage of Obama's Legacy;
Opinion
BYLINE: JULIAN E. ZELIZER
SECTION: OPINION; sunday
LENGTH: 1277 words
HIGHLIGHT: His major reforms are on the chopping block. But there is hope that some may be saved.
Three days after the election, I gathered with a group of historians at Princeton for a conference about Barack Obama's presidency. The mood among the scholars, who had just written papers about the underappreciated accomplishments of the Obama administration, was bleak. We were discussing how quickly his programs would be dismantled, now that Republicans controlled the White House and Congress. Donald J. Trump's stunning election appeared to many to be a direct repudiation of the essential meaning of 2008, when the country elected its first African-American president.
Mr. Obama was a great policy maker, but not a great party builder. In the face of Republican intransigence, he still managed to get things done. But the strategies that made him successful - passing legislation by the narrowest partisan majority, refraining from boasting about what his reforms accomplished and, in the end, falling back on executive orders - are exactly what make his legacy so vulnerable.
Congressional Democrats frequently complained that the president's approach put them at risk. Seeking to expand government with a hidden hand, his policies were designed in such a way that made it hard for Democrats to claim credit for them. In public, he played down the scale of policies like the stimulus package so that they would not attract too much attention, or criticism. Whereas President Franklin D. Roosevelt made it clear that every public works project was a product of the New Deal, Americans usually had no idea what programs came from Mr. Obama's stimulus.
His programs tended to be extraordinarily complex, dependent on byzantine regulatory mechanisms rather than direct federal intervention, so they would be more palatable to moderates. Rather than have the government provide health insurance for all, the Affordable Care Act created exchanges and mandates. The Dodd-Frank bill did not erect strong regulations to enforce reform on Wall Street, but rather a web of rules and incentives.
When he couldn't win support for legislation, for everything from immigration reform to reducing carbon emissions, he relied on executive orders that could - and almost certainly will - be reversed by his successor.
Now Democrats are out of power, and his major policies are on the chopping block. The health care exchanges and the individual insurance mandate might be legislated out of existence. Mr. Trump is planning to jettison the Paris climate change agreement as well as the Iran nuclear deal. Young immigrants will no longer be protected from deportation. Republicans could use the Congressional Review Act to knock down dozens ofrules that were put in place since May, ranging from regulations guaranteeing paid sick leave to people working under federal contracts to consumer protections like the Food and Drug Administration's prohibition on selling antibacterial soaps.
There won't be enough votes to move forward with the Trans-Pacific Partnership agreement. Mr. Trump's bluster on foreign policy threatens to reverse the notable improvement in diplomatic relations that took place under Mr. Obama. The Department of Justice's efforts to enforce civil rights laws and reform policing will die the slow death of regulatory neglect. The balance of power in the Supreme Court will shift back to the right.
And policies are not the only things at risk. Republicans have attacked a basic set of ideas that Mr. Obama tried to promote. With Stephen K. Bannon, someone who has long appealed to anti-Semites and the "alt-right," serving as the president-elect's chief strategist, Mr. Trump will double down on his attacks against "political correctness" and social values like ethnic pluralism and gender equality.
Yet with all of this wreckage looming on the horizon, there is a glimmer of hope that some of Mr. Obama's legacy can be salvaged. In American history, there have been a number of elections that seemed to be a repudiation of the previous president, including those of Dwight D. Eisenhower in 1952, Ronald Reagan in 1980 and Barack Obama himself in 2008. But these did not produce the full-scale reversal of programs that some observers expected. The reason is what political scientists call the process of "policy feedback."
Once new policies are put in place, they can generate strong constituencies that will defend them from attack. "With those taxes in there, no damn politician can ever scrap my Social Security program," boasted Roosevelt, anticipating the dynamics that would make elderly entitlements a third rail in American politics. Voters come to depend on benefits, politicians are expected to protect them, and interest groups emerge that have a stake in their continuation. When this happens, a president's contributions can outlast the political coalition that created them.
Eisenhower left most of the New Deal alone. The Great Society survived the Reagan Revolution. And Mr. Obama failed to wipe away George W. Bush's counterterrorism program.
Mr. Trump will encounter strong resistance to revoking the Medicaid coverage that 12 million Americans now enjoy under Obamacare. Numerous Republican governors, including the future vice president, Mike Pence, pushed for the expansion of the rolls. Many of Mr. Trump's own supporters probably like the benefits they have received from the A.C.A., even if they don't realize it. Even Dodd-Frank, hardly popular on Wall Street, could survive now that firms have adjusted to deal with the new rules. With only a narrow majority in the Senate, the G.O.P. will contend with constant obstruction as it tries to gut Mr. Obama's programs.
On foreign policy, Mr. Trump's tone is far from Mr. Obama's cool demeanor. And yet he is unlikely to pull out of NATO, and his push to pressure European states into contributing more to their collective defense actually builds on statements that Mr. Obama had been making. Mr. Trump is likely to find strong pushback from Congress and the public, as well as pivotal allies overseas, against any substantial change in a post-Iraq world where support for large-scale war remains thin and when we need allies to combat the threat posed by the Islamic State.
Finally, the election and re-election of an African-American to the presidency were watershed moments and will remain so even after the victory of a reactionary candidate.
The Obama years helped inspire new social activism, from Black Lives Matter to the Bernie Sanders campaign, that will remain a powerful force within the Democratic coalition. And the nation has shown that there is much deeper support for values like ethnic pluralism than Mr. Trump's election suggests. According to a recentpoll, 54 percent of Americans support a path to citizenship for immigrants already in our borders. Gallup has found that fewer than a third of the Americans it polled thought that imposing a religious test on people who entered the country and barring Muslims would be effective in combating terrorism.
Many more, nonetheless, supported Mr. Trump. But it is significant that the candidate running as a defender of Mr. Obama's legacy, Hillary Clinton, won over a million more popular votes.
Democrats now need to focus on the party-building that Mr. Obama neglected, so that the next time they find themselves in power, they can build on whatever remains of the policies he left behind.
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Julian E. Zelizer is a historian at Princeton, a fellow at New America and the author of "The Fierce Urgency of Now: Lyndon Johnson, Congress, and the Battle for the Great Society."
DRAWING (DRAWING BY EIKO OJALA)
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September 23, 2015 Wednesday
Late Edition - Final
U.S. Focuses on Uninsured in 4 States for Enrollment
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 767 words
WASHINGTON -- With the third open enrollment season under the Affordable Care Act beginning in about six weeks, Obama administration officials said Tuesday that they would focus efforts to expand health coverage to the uninsured in Dallas, Houston, northern New Jersey, Chicago and Miami.
''Over all, this open enrollment period is going to be tougher than last year,'' Sylvia Mathews Burwell, the secretary of health and human services, said in a speech here at Howard University Hospital. Many of the uninsured have already signed up, she noted, shrinking the pool of eligible people who do not have coverage.
And ''with our economy improving,'' she said, ''more people can get coverage under employer plans.''
Ms. Burwell said the administration would focus on 10.5 million uninsured Americans who were eligible for coverage through the public insurance exchanges, also known as marketplaces.
The enrollment period runs from Nov. 1 through Jan. 31, 2016, and she encouraged Americans to prepare.
At the end of the year, Ms. Burwell said, ''we expect that 9.1 million individuals will have active coverage through the marketplace'' -- the federal and state exchanges where consumers can shop for insurance. That number is down from 10.2 million at the end of March and 9.9 million at end of June. Some people failed to pay their premiums, and others could not adequately answer federal questions about their citizenship or immigration status.
Ms. Burwell did not state a numerical goal for enrollment in the coming year. The Congressional Budget Office predicted in March that enrollment through the exchanges would reach 11 million this year and 21 million in 2016.
But administration officials said those forecasts were based on two assumptions that inflated the numbers but have proved invalid. One assumption was that significant numbers of employers would drop insurance coverage and send their workers into the new insurance exchanges, but that has not happened, the officials said. The Congressional Budget Office also assumed that few consumers would buy insurance on their own outside of the new exchanges, but some have done so, officials said.
Under the 2010 health care law, consumers who buy private insurance on their own, outside of the exchanges, cannot obtain federal subsidies for such policies. The subsidies are available only for insurance purchased through the public exchanges.
While the federal government will try to increase coverage across the country, Ms. Burwell said, officials will focus on ''the top five targeted areas'' where many of the uninsured live, in Texas, New Jersey, Illinois and Florida.
Ms. Burwell acknowledged that ''costs are still a big concern,'' with many consumers ''worried about fitting premiums into their budgets.'' People with the greatest need for coverage have probably obtained it, officials said, and many of those who remain uninsured have passed up opportunities or disregarded the threat of tax penalties for going without insurance.
Ms. Burwell offered this profile of the 10.5 million uninsured Americans who she said were eligible for coverage through the exchanges:
Almost half of the ''eligible uninsured'' are 18 to 34.
Almost 40 percent of them have incomes from 139 percent to 250 percent of the federal poverty level (about $34,000 to $61,000 a year for a family of four). So they qualify for tax credits to help pay premiums and discounts to reduce their co-payments and other out-of-pocket costs.
About one-third are members of minority groups. Nineteen percent are Hispanic, 14 percent are African-American and 2 percent are Asian-American.
The Census Bureau reported last week that the number of people without health insurance dropped last year by 8.8 million, as major provisions of the Affordable Care Act took effect. But the bureau said 33 million people were still uninsured in 2014.
Based on a national survey of 1,270 uninsured adults, done for the Robert Wood Johnson Foundation, Ms. Burwell said that about half of the uninsured had less than $100 in savings. And nearly three in five are confused about how the tax credits work or do not know that they are available, she said.
Ms. Burwell said that consumers could sign up this fall without being deterred by political and legal fights that have raged over the health law for the last five years.
''Key provisions of the Affordable Care Act have twice been ratified by the highest court,'' she said.
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URL: http://www.nytimes.com/2015/09/23/us/politics/us-targets-four-states-in-effort-to-enroll-the-uninsured.html
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November 18, 2014 Tuesday
Late Edition - Final
Health Care Law Recasts Insurers as Obama Allies
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1329 words
WASHINGTON -- As Americans shop in the health insurance marketplace for a second year, President Obama is depending more than ever on the insurance companies that five years ago he accused of padding profits and canceling coverage for the sick.
Those same insurers have long viewed government as an unreliable business partner that imposed taxes, fees and countless regulations and had the power to cut payment rates and cap profit margins.
But since the Affordable Care Act was enacted in 2010, the relationship between the Obama administration and insurers has evolved into a powerful, mutually beneficial partnership that has been a boon to the nation's largest private health plans and led to a profitable surge in their Medicaid enrollment.
The insurers in turn have provided crucial support to Mr. Obama in court battles over the health care law, including a case now before the Supreme Court challenging the federal subsidies paid to insurance companies on behalf of low- and moderate-income consumers. Last fall, a unit of one of the nation's largest insurers, UnitedHealth Group, helped the administration repair the HealthCare.gov website after it crashed in the opening days of enrollment.
''Insurers and the government have developed a symbiotic relationship, nurtured by tens of billions of dollars that flow from the federal Treasury to insurers each year,'' said Michael F. Cannon, director of health policy studies at the libertarian Cato Institute.
So much so, in fact, that insurers may soon be on a collision course with the Republican majority in the new Congress. Insurers, often aligned with Republicans in the past, have built their business plans around the law and will strenuously resist Republican efforts to dismantle it. Since Mr. Obama signed the law, share prices for four of the major insurance companies -- Aetna, Cigna, Humana and UnitedHealth -- have more than doubled, while the Standard & Poor's 500-stock index has increased about 70 percent.
''These companies all look at government programs as growth markets,'' said Michael J. Tuffin, a former executive vice president of America's Health Insurance Plans, the main lobby for the industry. ''There will be nearly $2 trillion of subsidized coverage through insurance exchanges and Medicaid over the next 10 years. These are pragmatic companies. They will follow the customer.''
The relationship is expected only to deepen as the two sides grow more intertwined.
Consumers are already hearing the same messages from insurance companies and the government urging them to sign up for health plans during the three-month enrollment period. Federal law requires most Americans to have coverage, insurers provide it, and the government subsidizes it.
''We are in this together,'' Kevin J. Counihan, the chief executive of the federal insurance marketplace, told insurers at a recent conference in Washington. ''You have been our partners,'' and for that, he said, ''we are very grateful.''
Despite Mr. Obama's denunciations of insurers in 2009, it became inevitable that they would have a central role in expanding coverage under the Affordable Care Act later that year when Congress ruled out a government-run health plan -- the ''public option.'' But friction between insurers and the Obama administration continued into 2013 as the industry bristled at stringent rules imposed on carriers in the name of consumer protection.
A turning point came last fall, after the chaotic debut of HealthCare.gov, when insurers waived enrollment deadlines and helped the White House fix the dysfunctional website.
Now insurers say government business is growing much faster than the market for commercial employer-sponsored coverage. The Congressional Budget Office estimates that 170 million people will have coverage through Medicare, Medicaid and the insurance exchanges by 2023, an increase of about 50 percent from 2013. By contrast, the number of people with employer-based coverage is expected to rise just 2 percent, to 159 million.
In addition, the Affordable Care Act has engendered growth in the role of private insurers in Medicaid. The law expanded eligibility for Medicaid, and most of the new beneficiaries receive care from private health plans under contracts awarded by state Medicaid agencies. As a result, Medicaid enrollment is up more than eight million, or 15 percent, in the last year.
In a survey of 10 insurance companies, Joshua R. Raskin, an analyst at Barclays, reported that their revenues from the Medicare Advantage program were up about 10 percent this year. UnitedHealth Group's Medicaid enrollment surged by nearly one million people, or 24 percent, in the last year, said Stephen J. Hemsley, the chief executive. At another large insurer, WellPoint, the expansion of Medicaid ''is proving highly profitable,'' Christine Arnold, a managing director of Cowen and Company, wrote in a recent report.
WellPoint is a case study in how companies have adapted to the law.
In 2010, as Democrats attacked the insurance industry for what they said were its high prices and discriminatory practices, no company was more of a target than WellPoint, which had sought rate increases of up to 39 percent in California. But WellPoint, which operates Blue Cross and Blue Shield plans in a number of states, is now prospering.
WellPoint announced recently that it had gained 751,000 subscribers through the health insurance exchanges and 699,000 new members through Medicaid. Since the end of 2013, WellPoint's Medicaid enrollment has increased by 16 percent, to a total of five million.
''Our government business is growing along multiple fronts'' and accounted for about 45 percent of the company's consolidated operating revenues, said Joseph R. Swedish, the chief executive of WellPoint.
Aetna, in reporting its third-quarter results, said many people thought 2014 would ''spell the death of our industry.'' But, the company said, it is having ''a very good year,'' thanks in part to ''excellent performance in our government business, which now represents more than 40 percent of our health premiums.''
Insurers and the administration still have many disagreements, but open conflicts are rare.
''With all the politics of the Affordable Care Act, people don't realize how much the industry has benefited, and will continue to benefit, from the law,'' said Jay Angoff, the Obama administration's top insurance regulator from 2010 through 2012.
One insurer, Humana, derives about 65 percent of its revenue from its Medicare Advantage plans. Enrollment in these plans climbed 17.5 percent, to 2.9 million, in the year that ended Sept. 30, the company said.
At UnitedHealth Group, Medicaid and Medicare Advantage together are expected to provide more than $60 billion in revenue, or slightly less than half of the company's total, this year. United expects to participate in insurance exchanges in 23 states next year, up from four this year.
''The government, as a benefit sponsor, has been increasingly relying on private sector programs,'' United said in a document filed with the Securities and Exchange Commission. ''We expect this trend to continue.''
In another sign of the close relationship, the administration has recruited experts from the industry to provide operational expertise. Eight months after the unit of UnitedHealth Group, called Optum, helped repair HealthCare.gov, the administration hired a top Optum executive, Andrew M. Slavitt, as the No. 2 official at the Centers for Medicare and Medicaid Services. The administration waived conflict-of-interest rules so Mr. Slavitt could participate in decisions affecting UnitedHealth and Optum.
Now, as millions of Americans shop for insurance, federal officials are eager to collaborate with an industry they once demonized.
''The relationship between the marketplace and insurers is really critical to a successful program,'' said Ben Walker, director of open enrollment for the federal exchange. ''Without that, we don't have any coverage.''
URL: http://www.nytimes.com/2014/11/18/us/politics/health-law-turns-obama-and-insurers-into-allies.html
LOAD-DATE: November 18, 2014
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December 14, 2013 Saturday
Late Edition - Final
Under Health Law, Independent Practitioners in City Face Canceled Policies
BYLINE: By ANEMONA HARTOCOLLIS
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 16
LENGTH: 1190 words
Many in New York's professional and cultural elite have long supported President Obama's health care plan. But now, to their surprise, thousands of writers, opera singers, music teachers, photographers, doctors, lawyers and others are learning that their health insurance plans are being canceled and they may have to pay more to get comparable coverage, if they can find it.
They are part of an unusual, informal health insurance system that has developed in New York, in which independent practitioners were able to get lower insurance rates through group plans, typically set up by their professional associations or chambers of commerce. That allowed them to avoid the sky-high rates in New York's individual insurance market, historically among the most expensive in the country.
But under the Affordable Care Act, they will be treated as individuals, responsible for their own insurance policies. For many of them, that is likely to mean they will no longer have access to a wide network of doctors and a range of plans tailored to their needs. And many of them are finding that if they want to keep their premiums from rising, they will have to accept higher deductible and co-pay costs or inferior coverage.
''I couldn't sleep because of it,'' said Barbara Meinwald, a solo practitioner lawyer in Manhattan.
Ms. Meinwald, 61, has been paying $10,000 a year for her insurance through the New York City Bar. A broker told her that a new temporary plan with fewer doctors would cost $5,000 more, after factoring in the cost of her medications.
Ms. Meinwald also looked on the state's health insurance exchange. But she said she found that those plans did not have a good choice of doctors, and that it was hard to even find out who the doctors were, and which hospitals were covered. ''It's like you're blindfolded and you're told that you have to buy something,'' she said.
The people affected include not just writers, artists, doctors and the like, but also independent tradespeople, like home builders or carpenters, who work on their own.
Some have received notices already; others, whose plans have not yet expired, will soon receive letters in the mail. It is unclear exactly how many New Yorkers are affected; according to state health officials, as many as 400,000 independent practitioners get health insurance through job-related group plans, but that number also includes people who receive coverage through their spouses' employers.
The predicament is similar to that of millions of Americans who discovered this fall that their existing policies were being canceled because of the Affordable Care Act. The crescendo of outrage led to Mr. Obama's offer to restore their policies, though some states that have their own exchanges, like California and New York, have said they will not do so.
But while those policies, by and large, had been canceled because they did not meet the law's requirements for minimum coverage, many of the New York policies being canceled meet and often exceed the standards, brokers say. The rationale for disqualifying those policies, said Larry Levitt, a health policy expert at the Kaiser Family Foundation, was to prevent associations from selling insurance to healthy members who are needed to keep the new health exchanges financially viable.
Siphoning those people, Mr. Levitt said, would leave the pool of health exchange customers ''smaller and disproportionately sicker,'' and would drive up rates.
Alicia Hartinger, a spokeswoman for the Centers for Medicare and Medicaid Services, said independent practitioners ''will generally have an equal level of protection in the individual market as they would have if they were buying in the small-group market.'' She said the president's offer to restore canceled polices temporarily applied to association coverage, if states and insurers agreed. New York has no plans to do so.
Donna Frescatore, executive director of New York State of Health, the state insurance exchange, said that on a positive note, about half of those affected would qualify for subsidized insurance under the new health exchange because they had incomes under 400 percent of the poverty level, about $46,000 for an individual.
But many professionals make too much money to qualify for the subsidies, and even if they are able to find comparably priced insurance, the new policies do not have the coverage they are accustomed to.
David Rubin, vice president of Teiget, the Entertainment Industry Group Insurance Trust, which had served as a broker for about 1,000 members of creative guilds, said a big complaint was that in New York City and much of the state, the new individual plans both on and off the exchange did not allow patients to go to doctors out of network. ''All these people had these customized plans which are better than most of the things out there, and most of them are saving only a small amount of money,'' Mr. Rubin said.
Roy Lyons, managing director of Marsh U.S. Consumer, an insurance brokerage, said he had heard complaints from physicians, lawyers, pharmacists and optometrists. ''At first they think it's the bar association making the decision or the insurance company doing it,'' Mr. Lyons said. ''We have to explain that this is the Affordable Care Act; that's what was put into law. Once they understand, they're less emotional, but they're not happy with it.''
Among those affected are members of the Authors Guild; the Advertising Photographers of America; the Suzuki Association of the Americas, a music teachers organization; the Society of Children's Book Writers and Illustrators; the New York City Bar Association; and the New York County Medical Society. (One group, the Freelancers Union, negotiated a one-year exemption with the state.)
''One of the reasons to join a society is to get health insurance,'' said Dr. Paul N. Orloff, president of the New York County Medical Society. Even doctors pay a lot for coverage, he said, because the days of trading medical care with colleagues are long gone. ''In the old days, professional courtesy was the norm,'' Dr. Orloff said.
The medical society has not yet formally notified its solo practitioners, because their insurance plans do not expire until April. But those letters will be going out soon, officials said.
It is not lost on many of the professionals that they are exactly the sort of people -- liberal, concerned with social justice -- who supported the Obama health plan in the first place. Ms. Meinwald, the lawyer, said she was a lifelong Democrat who still supported better health care for all, but had she known what was in store for her, she would have voted for Mitt Romney.
It is an uncomfortable position for many members of the creative classes to be in.
''We are the Obama people,'' said Camille Sweeney, a New York writer and member of the Authors Guild. Her insurance is being canceled, and she is dismayed that neither her pediatrician nor her general practitioner appears to be on the exchange plans. What to do has become a hot topic on Facebook and at dinner parties frequented by her fellow writers and artists.
''I'm for it,'' she said. ''But what is the reality of it?''
URL: http://www.nytimes.com/2013/12/14/nyregion/with-affordable-care-act-canceled-policies-for-new-york-professionals.html
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March 28, 2012 Wednesday
If Health Law Is Overturned, What Will Liberals Do?
BYLINE: MICHAEL D. SHEAR
SECTION: US; politics
LENGTH: 922 words
HIGHLIGHT: For many progressive activists and voters, the decision by the court in June could reopen a debate that they thought they lost two years ago.
If the Supreme Court strikes down all or part of President Obama's health care law, it will have unraveled a legislative compromise that many liberals had viewed with suspicion from the beginning.
In one of the ironies of recent politics, Mr. Obama was a late convert to the merits of the individual mandate that now appears to be in danger of being declared unconstitutional.
But the president's embrace of the mandate - and his willingness to abandon a so-called public option to get a health care deal - was a hard pill to swallow for many of his Democratic supporters.
The Affordable Care Act promises to provide health insurance to millions who lacked it. But it also stops far short of the idea that health care is a basic right for everyone living in the country. And it embraces the market-based system of private health care delivery that has long existed in America.
For many progressive activists and voters, the decision by the court in June could reopen a debate that they thought they had lost two years ago. Rather than be dismayed if the court overturns the health care law, some liberals may see it as an unexpected opportunity.
Politically, there is almost no chance of a new effort to achieve universal health care coverage before the election in the fall. But if the current law is overturned, eventually there would be a new push from Democrats to achieve the goals they have pursued for decades.
Still, it's far from clear how progressives might regroup if the court rules against the mandate, as Tuesday's questions from the justices suggested they might.
Here are three possibilities:
SALVAGE: If the justices invalidate the individual mandate but stop short of declaring the entire law unconstitutional, progressives could try to fix it through other means.
Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology, has suggested a couple of options. Mr. Gruber was an adviser to both Mitt Romney on his health care plan in Massachusetts and to Mr. Obama.
In a paper written last year for the Center for American Progress, a research and advocacy group, he said the mandate could be replaced by a requirement that people "auto-enroll" in health insurance but with the ability to opt out if they wanted to.
Or, he said, people could be encouraged to buy insurance, and fined a penalty if they signed up after a deadline. That might encourage more participation in the health insurance market by young, healthy people.
But Mr. Gruber concluded that neither would be particularly effective, saying that "both alternatives significantly erode the gains in public health and insurance affordability made possible by the Affordable Care Act."
EXPAND: If the court declares large parts of the health care law unconstitutional, another option for liberals would be a return to advocating other methods to expand the number of people covered by insurance.
They could push for an expansion of Medicare to include coverage of people at an earlier age. And they could seek to include more people in government-run health care programs that cover children and the poor.
Neera Tanden, president of the Center for American Progress, said she remained hopeful that the court would uphold the health care law. But if it doesn't, she said she remained skeptical about other proposals.
"There is no proposal that I am aware of that operates without an individual mandate that gets you to that level of coverage," she said in an interview with The Caucus on Tuesday.
Congress would be unwilling to act on expansions of government health care programs if the current law is invalidated.
"We are a long way away," from another successful legislative effort on health care, she said. "It would be decades, and may not be in my lifetime."
SINGLE PAYER: If Democrats make little progress on alternatives, some purists might decide it's best to just renew the case for a single-payer system in which all Americans receive health care paid for by the government.
Sidney M. Wolfe, the director of the Health Research Group at Public Citizen, an advocacy group, has been pushing for government-run health care for decades.
In an interview Tuesday, Mr. Wolfe said a ruling against the current law could help start a renewed drive for a system that essentially expanded Medicare into a program for everyone, not just the elderly.
"If this is what happens, it may offer more incentive to say let's decide once and for all that health care is a right," Mr. Wolfe said. "It will certainly present an opportunity to a number of people."
But it's not clear where the support for such a change would come from, especially after the bruising fight over Mr. Obama's health care plan two years ago. Ms. Tanden said that she did not believe the country would support such a change.
"I am not holding my breath for the Medicare-for-all option. Most people in America feel comfortable with the health insurance they have," she said. "I would say to my progressive allies: the reason we have all been supporting the individual mandate is because it is the way in which we can get to near-universal coverage in my lifetime."
"They may look at this as an opportunity to carry that torch again," she added. "I don't think the Congressional response is to look at single-payer as the option."
Court Health Care Decision Poses Risks For Romney
Supreme Court Ruling Could Revive Health Care for 2012 Campaign
Santorum and Foes Spar on Day of Health Care Hearing
White House May Look to Compromise on Contraception Decision
Romney Confronts Health Care Questions
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January 26, 2012 Thursday
Health Insurance Deductibles Doubled in 7 Years, Study Finds
BYLINE: ANN CARRNS
SECTION: YOUR-MONEY
LENGTH: 396 words
HIGHLIGHT: Average deductibles for employer-based, family health insurance doubled from 2003 to 2010, a report from the Commonwealth Fund finds.
1/27/12 | Updated
If you've seen your health insurance premiums increase along with your deductible, you're not alone. A recent study by the Commonwealth Fund shows just how much more consumers are paying for employer-provided health insurance.
Total premiums -- the amount paid by both employers and workers combined -- for family coverage rose 50 percent from 2003 to 2010, to nearly $14,000 a year, the study found. (The fund is a private foundation that researches health policy issues. The report includes an interactive map showing premium increases by state.)
Workers, meanwhile, are shouldering more of that burden. Their share of annual premiums increased by 63 percent over the same period. In 2010, employee premiums for family-plan coverage averaged about $3,700, up from roughly $2,300 back in 2003.
As a result, "many working families have seen little or no growth in wages as they have, in effect, traded off wage increases just to hold onto their health benefits," the report found.
What's more, employees are paying more for less, because of higher deductibles -- the amount workers pay out of pocket before coverage kicks in. The average family deductible nearly doubled over the seven years studied, to almost $2,000 in 2010.
The study used annual employer data from the federal government to examine insurance cost trends in the 50 states and the District of Columbia.
Whether the rate of cost growth can be slowed, the report said, depends on the Affordable Care Act, which was passed in March 2010 and intended to go into effect over several years. The act has, for instance, rules to limit what insurance companies can spend on administrative costs and can be "a platform for further action," the report said.
In November, however, the Supreme Court agreed to hear a challengeto the healthcare overhaul law, throwing some of its provisions into question.
"With rising costs and eroding coverage, much is at stake for the insured and uninsured alike as the nation looks forward," the report concluded.
If you have employer-based health insurance, how are you handling increases in your premiums and deductibles?
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Bank of America Equalizes Health Costs for Gay Employees
Will High-Deductible Health Insurance Plans Become the Norm?
Medical Debt Cited More Often in Bankruptcies
Can a New Form Make Health Insurance Decisions Easier?
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The New York Times
November 3, 2013 Sunday
Late Edition - Final
What's On Sunday
BYLINE: By KATHRYN SHATTUCK
SECTION: Section SP; Column 0; Sports Desk; Pg. 11
LENGTH: 700 words
7 P.M. (BET) BLACK GIRLS ROCK! Black Girls Rock!, a nonprofit organization dedicated to the emotional development of young black women, joins forces with BET to pay tribute to role models in professional and public service. Tracee Ellis Ross and Regina King host this special, taped at the New Jersey Performing Arts Center in Newark, honoring women in business, politics, entertainment, sports and community service, including Queen Latifah, Patti LaBelle, Venus Williams, Misty Copeland, Marian Wright Edelman and Ameena Matthews. Performers include Ledisi, foreground above, and Jennifer Hudson, Kelly Rowland, Janelle Monáe, Sevyn Streeter and Amber Riley.
10 A.M. (ABC) THIS WEEK George Stephanopoulos interviews Dan Pfeiffer, a senior White House adviser, and Senator Rand Paul, Republican of Kentucky, about the Affordable Care Act rollout and continued fallout over spying by the National Security Agency. Nate Silver, the statistician and editor in chief of FiveThirtyEight.com, makes his ABC News debut with an analysis of the 2014 midterm elections.
10 A.M. (Fox) FOX NEWS SUNDAY Chris Wallace interviews Dr. Ezekiel J. Emanuel, a vice provost at the University of Pennsylvania and an oncologist who advised the White House on health care reform, and James C. Capretta, a senior fellow at the Ethics & Public Policy Center, about the rollout of the Affordable Care Act.
10:30 A.M. (CBS) FACE THE NATION The guests include Senator Dianne Feinstein, Democrat of California; Representative Mike Rogers, Republican of Michigan; and Michael V. Hayden, the former director of the National Security Agency.
10:30 A.M. (NBC) MEET THE PRESS David Gregory interviews Mitt Romney, the former Republican presidential nominee and Massachusetts governor, about the rollout of the Affordable Care Act.
7:30 P.M. (CBS) 60 MINUTES Lesley Stahl visits the prison at Guantánamo Bay, Cuba. Scott Pelley drives a Lamborghini at 155 miles an hour. And Armen Keteyian watches Nick Saban coach his University of Alabama football team.
8 P.M. (13, 49) SECRETS OF SELFRIDGES Selfridges, left, is a London institution, but it was an American, Harry Gordon Selfridge, who revolutionized the way Britons shopped, introducing a retail model that made it less a practical pursuit than a luxurious adventure. This special looks at the department store's mastermind, who coined the expression ''The customer is always right.'' In ''The Paradise,'' on ''Masterpiece Classic'' at 9, exotic lovebirds are put up for sale at the store, and Denise (Joanna Vanderham) struggles to hide her feelings for Moray (Emun Elliott).
8 P.M. (Reelz) JFK: THE SMOKING GUN The detective Colin McLaren tries to make the case that the Secret Service agent George Hickey accidentally fired the fatal bullet that struck President Kennedy's head.
8 P.M. (Fox) THE SIMPSONS In ''Four Regrettings and a Funeral,'' Springfield residents request a do-over when a beloved member of the community dies. Rachel Maddow (left, as a cartoon) and Joe Namath voice themselves.
9 P.M. (CUNY) THE RED HOUSE (1947) A teenager (Allene Roberts) raised by a disabled farmer (Edward G. Robinson) and his sister (Judith Anderson) persuades a friend (Lon McCallister) to explore a sinister house from which screams emanate at night, despite her foster father's warning, in this psychological thriller directed by Delmer Daves. Writing in The New York Times, Archer Winston said that the movie's ''cumulative effect'' was ''as eerie as a well-spun ghost story.''
9 P.M. (Al Jazeera America) OPEN SECRETS Steve Lickteig, an NPR producer, recounts his 20-year search for his biological parents and the Kansas town that kept the secret of his birth mother from him.
9:30 P.M. (CBS) THE GOOD WIFE Alicia (Julianna Margulies) and Cary (Matt Czuchry) must find a way to represent a client who left Lockhart Gardner for Florrick Agos after Will (Josh Charles) and Diane (Christine Baranski) delay handing over files.
10 P.M. (Showtime) MASTERS OF SEX Masters (Michael Sheen) travels with Libby (Caitlin FitzGerald) to Miami for a vacation after the loss of their baby but finds himself lured back to his work by a sexually adventurous couple in the hotel room next door.
KATHRYN SHATTUCK
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August 21, 2012 Tuesday
Ryan Takes to Pennsylvania to Push Medicare Message
BYLINE: TRIP GABRIEL
SECTION: US; politics
LENGTH: 363 words
HIGHLIGHT: The Republican vice-presidential candidate reminded Pennsylvania voters of President Obama's "guns and religion" remark.
WEST CHESTER, Pa. -- Representative Paul D. Ryan of Wisconsin customized from his menu of attacks on President Obama to fit a full day of campaigning in Pennsylvania on Tuesday, putting state-specific numbers on his assertion that current Medicare beneficiaries will suffer benefit cuts under the 2010 health care law.
"In Pennsylvania, 38 percent of Pennsylvania seniors choose to get their Medicare from a plan called Medicare Advantage,'' Mr. Ryan said here. "Forty-seven percent of them are going to lose it under Obamacare, according to Medicare, by 2017.''
Mr. Ryan was extrapolating from a 2010 report from Medicare's Office of the Actuary. It analyzed the potential impact of lower premium supports paid to private companies that issue Medicare Advantage plans, popular alternatives to traditional Medicare with extra benefits such as gym memberships. To slow the growth of Medicare spending, the Affordable Care Act reduces support for the private plans, which Democrats consider inefficient. Beneficiaries would still be covered under traditional Medicare.
But Mr. Ryan and Mitt Romney have raised the charge that the health care overhaul "raided" Medicare to help pay for "Obamacare.''
"The next time you hear from President Obama, tell him to keep his hands off Medicare," Mr. Ryan said, continuing to turn the tables on an issue that many strategists expected to be a weakness for the Republican ticket with Mr. Ryan coming aboard, because of his signature plan to turn Medicare into an optional voucherlike system.
The risk was highlighted by a national telephone poll conducted Aug. 16 to 19 by the Pew Research Center that showed that of those who have heard of Mr. Ryan's plan, 49 percent oppose such a reform and 34 percent favor it.
Speaking to a boisterous crowd outside a helicopter museum here west of Philadelphia, Mr. Ryan also needled Mr. Obama over one of his best-remembered gaffes of the 2008 campaign. Mr. Ryan also customized the line for his local audience.
"You remember that one where he said people in places like Pennsylvania and Wisconsin, we cling to our guns and our religion?'' he said. "Hey. As a Catholic deer hunter: guilty as charged.''
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The New York Times
October 13, 2015 Tuesday
Late Edition - Final
As Consumers Face Complex Choices, HealthCare.gov Will Get a Makeover
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 1088 words
WASHINGTON -- Acknowledging at least tacitly the difficulties of some health care consumers, the Obama administration plans major changes to HealthCare.gov this year to make it easier for shoppers to find health insurance plans that include their doctors and to predict their health care costs for the coming year.
With substantial premium increases coming in some states in 2016, administration officials are expecting that many consumers already in the Affordable Care Act's networks will have to switch health plans and find new doctors as they scramble for cheaper alternatives. And millions more Americans could be receiving health insurance through health care marketplaces for the first time.
But insurers in many counties are offering such a dizzying array of health insurance plans with so many subtle differences that consumers have struggled to determine which plan is best for them.
''Normal consumers just cannot assess the dollar consequences of their decisions,'' said Robert M. Krughoff, the president of the Center for the Study of Services, also known as Consumers' Checkbook. ''Is a $200 deductible with a $10,000 out-of-pocket limit better for my family than a $2,000 deductible and a $4,000 out-of-pocket limit?''
With the Affordable Care Act's third open enrollment season starting Nov. 1, new features of HealthCare.gov will allow consumers to type in the names of their doctors, prescription drugs and preferred hospitals, and see which plans cover them, administration officials said.
The effort to ease the consumer experience is driven by the administration's push to reach the 10.5 million people who Sylvia Mathews Burwell, the secretary of Health and Human Services, says are still uninsured but eligible for marketplace coverage. While 9.9 million people have received health insurance through the exchanges as of June 30, the law has far to go to reach the 21 million people the Congressional Budget Office estimated in March would be enrolled next year. Federal health officials say that target is too optimistic, but they have yet to announce their own numerical goal.
The new search tools are important for several reasons. Most insurers try to hold down costs by creating networks of selected doctors and hospitals, and patients typically face higher costs if they go outside the network.
Until now, people using HealthCare.gov generally had to visit the website of each insurer to see which doctors and hospitals were in its network and which drugs were on its list of preferred medications. That could be a cumbersome, time-consuming task.
Since passage of the Affordable Care Act in 2010, consumer advocates have been pleading with the Obama administration to create ''decision support tools'' to help people sort through health plans in the online marketplace.
Insurers said the new tools could be helpful, but had not been fully tested. In any event, they said, if consumers have any questions, they should call the doctor's office and the insurance company to confirm if a particular provider is in its network.
New research shows what is at stake. A study by HealthPocket, a technology company, found that nearly half of health plans sold in the federal insurance marketplace did not provide coverage for services outside the network, so patients bore most of the cost. A separate study by America's Health Insurance Plans, a trade group for insurers, said that out-of-network providers typically billed patients for amounts far exceeding what Medicare pays for the same services.
''Choosing a health plan is really complicated,'' said Dr. Charlene A. Wong, a pediatrician and health policy researcher at the University of Pennsylvania. ''With the rise of narrow networks, it is increasingly important for consumers to have provider-lookup tools so they can see which plans include their preferred doctors and hospitals.''
Under a new federal rule, insurers must publish their drug lists and doctor directories in a ''machine readable'' format that allows software developers to manipulate the data for myriad purposes, just as they do with stock quotations.
In the last two years, the federal marketplace tended to steer people toward health plans with the lowest premiums, even though such plans often have high out-of-pocket costs so consumers end up spending more.
The changes to HealthCare.gov will include a cost-comparison tool for consumers to estimate their probable out-of-pocket and total costs, including premiums, deductibles and other charges, under different health plans.
To make such estimates, the website will ask consumers if they think their use of medical care in 2016 will be low, medium or high, and the website then will provide an estimate of costs for each plan.
In making calculations, the government uses a person's age, sex, income and ZIP code. The website will show premiums reduced by the amount of any subsidies that a family may receive in the form of tax credits, but consumers can also see the full price if they want.
Some private groups have even more sophisticated tools. Mr. Krughoff's group, Consumers' Checkbook, has developed such a tool, based on more than 30 years of experience in providing advice to federal employees on their health insurance options.
The tool, already used in Illinois, will be available this fall to consumers in Minnesota, Missouri and Washington, D.C.
In addition, Enroll America, a nonprofit group trying to expand coverage, has developed a digital tool to help consumers estimate their likely out-of-pocket costs for each plan available in their area. Consumers can also use it to find health plans that cover their drugs and preferred providers.
Enroll America devised the tool with Clear Health Analytics, based in Stamford, Conn. To help estimate costs, it asks if consumers have any of 11 common conditions. The conditions include asthma, back problems, diabetes, heart disease and breast, lung and prostate cancer. Women are asked if they are or plan to become pregnant.
Anne Filipic, the president of Enroll America, said such tools could transform the experience of shopping for insurance.
''In the past,'' Ms. Filipic said, ''people often got stuck trying to pick a plan that was right for them. They found the process overwhelming. If people can find a plan that better meets their needs, they are more likely to stick with it and stay insured.''
Follow the New York Times's politics and Washington coverage on Facebook and Twitter, and sign up for the First Draft politics newsletter.
URL: http://www.nytimes.com/2015/10/13/us/healthcaregov-to-get-major-changes-to-ease-shopping-for-coverage.html
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June 25, 2015 Thursday
Verbatim: Hillary Clinton Supports Supreme Court Decision
BYLINE: FIRST DRAFT
SECTION: US; politics
LENGTH: 31 words
HIGHLIGHT: Hillary Rodham Clinton showed her support on Twitter for the Supreme Court’s decision to uphold a key element of President Obama’s health care law.
Yes! SCOTUS affirms what we know is true in our hearts & under the law: Health insurance should be affordable & available to all. -H
- Hillary Clinton (@HillaryClinton) June 25, 2015
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The New York Times
November 1, 2014 Saturday
Late Edition - Final
G.O.P.'s Assault on Health Law Fades in Races
BYLINE: By JONATHAN WEISMAN
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1175 words
WASHINGTON -- In early October, with his poll numbers stubbornly lagging his Democratic opponent's, Ed Gillespie did something almost no other Republican candidate has done this campaign season. Mr. Gillespie -- a former lobbyist, former chairman of the Republican National Committee and now Senate candidate in Virginia -- unveiled a plan to replace the Affordable Care Act.
The proposal, which would use tax credits and a federally funded ''high-risk pool'' to cover the uninsured, opened him to criticism. It most likely would cover fewer people than President Obama's health care law, while having fewer statutory protections and still requiring billions from the federal government.
Almost no one questioned its seriousness, but almost no one took up the cause.
Republican attacks on the health care law dominated the early months of the campaign, but now have largely receded from view. The focus instead has been more on tethering Democratic candidates to Mr. Obama with a broad-brush condemnation of his policies.
And even though some Republican candidates still vow to repeal the law, almost none have offered an alternative. Mr. Gillespie and Mike McFadden, the Republican challenger to Senator Al Franken in Minnesota, stand as exceptions, to little effect. Like Mr. Gillespie in his race against Senator Mark Warner, Mr. McFadden holds little chance of defeating the incumbent on Tuesday.
''The A.C.A. is bad policy, but it was passed because of legitimate concerns about the affordability and accessibility of health care coverage,'' Mr. Gillespie said in an interview. ''And we need to show we share those concerns.''
Without stronger voices and a more robust policy debate, Tuesday's results are likely to leave no one to claim a mandate for a new direction if Republicans win control of the Senate.
''I'm here raising my hand saying we've got a health care problem in this country. I want straight talk,'' Mr. McFadden said in an interview Thursday. ''The idea that you repeal, everything goes away and we go back to the old system? The old system is bad. We have to address it.''
Even though Senator Mitch McConnell, Republican of Kentucky, who could become the majority leader if he wins re-election and his party nets six seats, has stuck by his promise to repeal the law ''root and branch,'' he has conceded that is quite unlikely to happen. Still, the outcome of the election will mean, particularly if Republicans do as well as forecast, that the debate over health care is not over.
''The leaders of the majority party in the House and Senate are likely to reflect the views of their party's adherents,'' two Harvard University scholars concluded in The New England Journal of Medicine. Their view is supported by public polling that shows a highly partisan assessment of the law. A Pew Research Center poll in September found that 83 percent of Republican likely voters say they want the law repealed or scaled back, an overwhelming sentiment that would be hard to ignore if Congress is in all-Republican hands next year.
But Mr. Obama would veto any attempt to repeal the law, so Republicans are left with lesser options.
Under Mr. Gillespie's plan, tax credits would be used by those without access to employer-provided health care to buy insurance on the individual or small-group market. People with an existing medical condition could not be dropped or see premiums rise as long as they maintained constant coverage. Those with existing health problems who could not find health plans would go to ''high-risk pools'' run by the states but financed with $7.5 billion in federal funds, an amount that would rise 3 percent a year.
According to the Center for Health Economy, whose board includes conservative and liberal health care economists, the plan would leave about six million fewer people insured in a decade, primarily because it would roll back Medicaid expansion. But, the center said, it would also lower the cost of less comprehensive health insurance plans, expand access to health care providers and cost $1 trillion less than the Affordable Care Act.
''In order to repeal Obamacare, we must present an alternative that is both practically effective and politically viable,'' Mr. Gillespie said when he unveiled his plan. ''Repeal efforts in the absence of an alternative plan have repeatedly fallen short.''
Under Mr. McFadden's plan, states that have established insurance exchanges under the health care law could keep them, and some federal subsidies could be available in the form of block grants to state governments. He, too, would establish state-run high-risk pools for people with existing conditions, at a cost he estimated to be $15 billion a year, much of which would come from Washington.
Unlike Mr. Gillespie, Mr. McFadden explicitly calls for maintaining the health care law's ban on lifetime coverage limits by private insurers.
At this point, the argument over whether to repeal and replace the health care law or change it is ''largely semantic,'' said Douglas Holtz-Eakin, a Republican member of the Center for Health Economy board who assessed Mr. Gillespie's plan. There are now at least five Republican replacement plans, and almost all of them share elements with the Affordable Care Act: tax credits to buy health insurance, protections for people with existing medical problems, a cap on the tax deductibility of employer-provided health insurance, and some definition of the kinds of health plans eligible for federal subsidies.
Senior Senate Republicans are already examining how they could use a parliamentary budget rule called reconciliation to gut the health care law, by curtailing or eliminating tax credits used to purchase insurance on the law's health exchanges and repealing its tax increases. Under reconciliation, such a move could not be filibustered by Democrats, but it could be vetoed by the president.
And reconciliation could not be used to alter parts of the law, such as regulations and mandates, that do not affect federal spending or revenues.
''It would take 60 votes in the Senate,'' Mr. McConnell told Fox News. ''No one thinks we're going to have 60 Republicans, and it would take a presidential signature.''
With millions of Americans already covered under the law and the second open-enrollment period beginning Nov. 15, it is unclear how forceful a Republican-controlled Congress would be.
If Republicans approach health care modestly and seek changes with bipartisan support, such as a repeal of the law's tax on medical devices, Democrats say they will be put in a difficult spot. If Republican leaders give their conservative voters what they want, it could enable the president's party to stage a comeback in 2016 by creating a clash over insurance coverage that Democrats think they could win.
''When I'm sitting in Washington in January, that means there's something like 10, 11, 12 new Republican senators,'' said Mr. McFadden, who, if he wins, will have caught a very large Republican wave. ''I guarantee you we will believe we have a mandate to reform health care.''
URL: http://www.nytimes.com/2014/11/01/us/politics/repeal-of-health-law-once-central-to-gop-is-side-issue-in-campaigns.html
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December 12, 2015 Saturday
Late Edition - Final
Poll Finds Support for Kentucky Medicaid Expansion
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1245 words
WASHINGTON -- More than seven in 10 residents of Kentucky want their new governor, Matt Bevin, to keep the state's expanded Medicaid program as it is, according to a new poll from the Kaiser Family Foundation. And more than half of respondents described Medicaid as important for themselves and their families, underscoring the program's substantial reach in the state and the challenges Mr. Bevin may face if he seeks to scale back or modify it.
Mr. Bevin, a Republican who took office Tuesday, is an opponent of the Affordable Care Act who earlier this year called for reversing the Medicaid expansion on the grounds that it was unaffordable for the state. He has since backpedaled to say he will seek changes requiring Medicaid enrollees to have ''skin in the game,'' such as by charging them monthly premiums.
''I do not intend to re-enroll people at this same level going forward,'' Mr. Bevin said in a news conference after his election.
Yet the Kaiser poll, conducted Nov. 18 through Dec. 1, found that 63 percent of Kentuckians have a favorable opinion of their state's Medicaid expansion. Support for the expanded Medicaid program was significant even among Republicans, of whom 54 percent said they would prefer to keep Medicaid as it is rather than scale it back to cover fewer people. Of respondents who voted for Mr. Bevin last month, 43 percent said they preferred keeping the program as it is now.
''This is a very poor state, and people here can't even afford to buy food,'' said one respondent, Daryl Tackett, 57, a Republican in Harrodsburg, Ky., who said he did not vote in the election. ''I don't want him to take the Medicaid away because there's too many people that needs it.''
Drew Altman, the president and chief executive of the Kaiser Family Foundation, a nonpartisan health research group, said the message of the polled seemed to be: '' 'We may not like Obamacare very much, but don't take my brother's or sister's or niece's Medicaid coverage away.' It's like there's an ideological side of people's brains but a practical side, too, that values the health benefits and the coverage.''
The Affordable Care Act gave states the option of expanding their Medicaid program to include all people younger than 65 with income at or below 138 percent of the federal poverty level, or $16,243 for a single person. Before the law's passage, enrollment was limited almost exclusively to children, pregnant women and the disabled.
Kentucky's former governor, Steven L. Beshear, a Democrat, expanded the program by executive order in January 2014, and since then, an additional 425,000 residents have joined the Medicaid rolls, most of them adults. By contrast, only 89,000 people have bought private coverage through Kynect, the state's health care exchange.
In all, 30 states have expanded Medicaid under the health law. Some Republican-led states, like Indiana, have won permission from the federal government to experiment with alternative ways of expanding the program, typically adding premium requirements and other rules that they describe as promoting personal responsibility. In his inaugural address, Mr. Bevin said he intended to ''copy the best parts'' of Indiana's program.
On the Affordable Care Act over all, respondents were far more divided, with more negative than positive leanings. Forty-nine percent said they viewed the law unfavorably, and 41 percent had a favorable view. Their opinions split sharply along party lines, mirroring national polls on the law. Opinions were also divided on whether the law had made health insurance more affordable: Thirty-six percent said it had, but about a third said it had made coverage less affordable.
Asked about the poll findings, Jessica Ditto, a spokeswoman for Mr. Bevin, said: ''Obamacare is not working in Kentucky, and Governor Bevin is committed to finding a practical and efficient solution that will improve health outcomes. The administration will take deliberate and prudent steps to develop a health care plan that Kentucky can afford.''
Over all, 72 percent of poll respondents said Mr. Bevin should keep Medicaid as it is, and 20 percent said he should scale it back so fewer people were covered. Ballard Ashlock, 43, a farmer in Crestwood, Ky., said he believed Mr. Bevin should scale back the program to exclude people who are capable of working but choose not to.
''I'm not a believer in people who get a free ride,'' said Mr. Ashlock, adding that he voted for Mr. Bevin despite being a Democrat. ''I'm sorry, but get a job.''
Mr. Altman said the level of support for the Medicaid expansion was striking especially given that most respondents incorrectly assumed Kentucky is paying most of the cost or splitting it with the federal government. In fact, the federal government currently pays 100 percent of Medicaid expansion costs, a share that will gradually drop to 90 percent in 2020 and beyond. The Beshear administration estimated the state's share of covering the new Medicaid enrollees would total $257 million over the next two budget years.
Mr. Bevin, who defeated his Democratic opponent by nine points, seems to have grasped the political complexities of changing aspects of the law; after backing away from his initial call to reverse the Medicaid expansion, he softened his language in discussing it.
''There is tremendous need; we know that,'' Mr. Bevin said in his inaugural address on Tuesday, referring to Medicaid recipients.
The poll found less robust support for keeping the online insurance exchange that Kentucky built under the health law: Fifty-two percent of respondents said they wanted to keep Kynect, and 26 percent said they wanted Kentucky to switch to the federal insurance exchange and 19 percent said they did not know. People whose income is too high for Medicaid can buy private coverage through these exchanges, and apply for federal subsidies to help with the cost.
People can also apply for Medicaid through Kynect, which the state built with $283 million in federal grants.
Mr. Bevin wants to dismantle Kynect and transition Kentucky to the federal insurance exchange, which 38 other states already use. Most of those states have Republican leaders who oppose the health law and rejected federal funds to build their own exchanges.
Fifty-six percent of the poll respondents said they knew adults who had gotten health insurance coverage through Kynect, but most said the coverage was Medicaid, not a private plan.
Underlying the support that the poll found for the expanded Medicaid program is the personal connection that many say they have to it. They include Janice Singleton, of Science Hill, Ky., who said her partner, a trucker, learned he had colon cancer after signing up for Medicaid last year.
Without the coverage, she said, ''He wouldn't have gone to the doctor and he wouldn't be here now.''
Ms. Singleton, a 52-year-old Republican, said that she, too, had qualified for Medicaid and would be willing to pay a monthly premium if she could afford it. The Medicaid expansion was a lifeline for many and should not be scaled back, she said, even though it would cost the state money over time.
''Sometimes, they spend money in places it doesn't need to be,'' Ms. Singleton said. ''But this is good spending.''
Interviews for the poll were conducted by landline and cellphone among a total sample of 1,017 adults across the state, with a margin of sampling error of plus or minus four percentage points.
URL: http://www.nytimes.com/2015/12/11/us/poll-finds-kentuckians-split-with-gov-matt-bevin-on-expanded-medicaid.html
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The New York Times
October 1, 2013 Tuesday
Late Edition - Final
Conservatives With a Cause: 'We're Right'
BYLINE: By ASHLEY PARKER
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1038 words
WASHINGTON -- Senator Claire McCaskill, Democrat of Missouri, was the first to take to the Senate floor to publicly pose a question gnawing at an increasing number of lawmakers and ordinary citizens alike as the deadline for a government shutdown neared: Has Congress gone completely crazy?
''It's very hard from a distance to figure out who has lost their minds,'' said Ms. McCaskill immediately after the Senate on Monday rejected a Republican plan to not finance the government unless Democrats agreed to delay the new health law. ''One party, the other party, all of us, the president.''
Senator Harry Reid, the Nevada Democrat and majority leader, had his own colorful, if somewhat skewed, metaphor about why much of the government was about to grind to halt in a take-no-political-prisoners fight over what is essentially a simple six-week funding bill, attributing it to the emergence of a ''banana Republican mind-set.''
Mr. Reid's language was evocative, and the implication was serious. With Democrats controlling the White House and Senate and with millions of dollars spent getting the health care law to the starting line, what gives House Republicans the idea that they can triumph in their push to repeal, or at least delay, the Affordable Care Act when so many veteran voices in their party see it as an unwinnable fight?
''Because we're right, simply because we're right,'' said Representative Steve King, Republican of Iowa, one of the most conservative of House lawmakers. ''We can recover from a political squabble, but we can never recover from Obamacare.''
Representative Raúl Labrador, Republican of Idaho and one of the original proponents of the so-called Defund Obamacare movement, was similarly sanguine. ''We can always win,'' he said Monday afternoon, as he jogged up the stairs to a closed-door conference meeting, where House Republicans gathered to plot their next move.
Representative Pete Sessions, Republican of Texas and chairman of the House Rules Committee, hinted that Republicans were unlikely to give up without at least another round since they see their campaign against the health care law as something of a higher quest. And many, if not most, people they talk to -- colleagues, friendly constituents, activists, members of advocacy groups -- reinforce that opinion, bolstering their belief that they are on the right side not just ideologically, but morally as well.
''This isn't the end of the road, guys,'' Mr. Sessions said with a grin. ''This is halftime.''
The distance between the House and the White House has never seemed greater.
While some House Republicans postulate that President Obama would secretly welcome a postponement of the law to avoid embarrassing bureaucratic problems, he has repeatedly made it clear that he would veto any bill that delays his signature health care law from taking full effect. But he would almost certainly never have to use his veto pen since Mr. Reid, who is incensed at Congressional conservatives, has also made clear that the Senate is unlikely to pass any spending bill that includes items from a Republican wish list, like delaying the health care law for individuals by one year.
As the House and Senate exchanged legislative volleys, the president accused his Republican opponents of an outrageous effort at extortion and reminded them that even if the government does shut down, his health care law will proceed largely unaltered.
''An important part of the Affordable Care Act takes effect tomorrow,'' Mr. Obama said, referring to the open enrollment process that begins Tuesday. ''That funding is already in place. You can't shut it down.''
Yet House Republicans remain undaunted -- and some even said publicly that winning is beside the point.
''What was I elected for? To try to change the law on behalf of my constituents, to stand on my core principles and do my best to represent them ethically, honestly, based on the core principles we share,'' said Representative John Culberson, Republican of Texas. ''This is a matter of core principle.''
Representative Steve Pearce, Republican of New Mexico, described the task facing his colleagues as perhaps quixotic, but ideologically critical. ''At times, you must act on principle and not ask what cost, what are the chances of success,'' he said.
Historically, stopgap measures to finance the government were routinely approved with bipartisan support and considered on their own merits as ''disputes about money,'' as Senator Barbara A. Mikulski, Democrat of Maryland, reminded her colleagues on the Senate floor on Monday. ''They were not about political, ideological viewpoints over past legislation,'' she said.
After being criticized by the Senate once again, House Republicans emerged Monday afternoon from their closed-door meeting with their latest distinctly political offering to the Senate, a bill that would link further government spending to a one-year delay of the new insurance requirement for individuals, as well as a proposal to force members of Congress, their staff, and White House staff, to buy their health coverage on the new exchanges without any government subsidies to offset the cost.
Senate Democrats immediately decried the plan as unacceptable, and even a portion of House Republicans expressed concern, angry that their leadership's proposal did not go far enough. Representative Michele Bachmann, Republican of Minnesota, said the only bill she could support would be one that included ''a full repeal for a year, which would be defund and delay.''
As the government inched closer to a shutdown, some House Republicans began expressing frustration at what they viewed as magical thinking from some of their colleagues.
''It's just leading us into a dead end,'' said Representative Peter T. King, Republican of New York, referring to his conference's latest offering. ''The Democrats are going to reject it, and the government's going to shut down.''
Representative Devin Nunes, Republican of California, likened the hard-line, conservative members of his conference to ''lemmings with suicide vests.''
''It's kind of an insult to lemmings to call them lemmings, so they'd have to be more than just a lemming, because jumping to your death is not enough,'' he said.
URL: http://www.nytimes.com/2013/10/01/us/politics/conservatives-with-a-cause-were-right.html
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GRAPHIC: PHOTOS: Clockwise from above, Speaker John A. Boehner heading to the House floor for a vote Monday night
lawmakers outside the Capitol
Senator Harry Reid on his way to a Senate Democratic caucus earlier on Monday to discuss a possible government shutdown. (PHOTOGRAPHS BY DOUG MILLS/THE NEW YORK TIMES) (A15) CHART: Back and Forth For the past 10 days, the Republican House, led by John A. Boehner of Ohio, and the Democratic Senate, led by Harry Reid of Nevada, have lobbed a spending bill between their two chambers. The bill would prevent the government from running out of money at 11:59 p.m. Sept. 30. (GRAPHIC BY KAREN YOURISH AND ARCHIE TSE/THE NEW YORK TIMES) (A15)
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April 18, 2014 Friday
Late Edition - Final
New Tax Takes Aim at Ranks of Superrich
BYLINE: By FLOYD NORRIS.
Floyd Norris comments on finance and the economy at nytimes.com/economix.
SECTION: Section B; Column 0; Business/Financial Desk; HIGH & LOW FINANCE; Pg. 1
LENGTH: 1242 words
Will this be the year that the superrich finally pay higher taxes than the very rich?
This is not, I admit, something that many people are worried about.
But it is an interesting fact that our current tax system assures that -- year after year -- the superrich, those who report adjusted gross incomes of more than $10 million, have tax rates that are significantly lower than those of the very rich, those earning more than $500,000 but less than $10 million.
Figures just released by the Internal Revenue Service show that in 2011 the difference in rates between the groups rose to 4.1 percentage points, the largest since the I.R.S. began calculating the data in 2000. The superrich paid 20.4 percent of their income in federal income taxes in 2011, while the very rich paid 24.5 percent.
On average, each of the 11,445 taxpayers who reported more than $10 million in income would have paid an extra million dollars in taxes if they had faced the same tax rates as the very rich.
Why are the superrich treated so well? It is largely because investment income -- what we used to call unearned income -- has long enjoyed preferential tax treatment. President Ronald Reagan briefly eliminated that preference in the Tax Reform Act of 1986, but it was restored within a few years and, until now, had tended to grow whenever the tax law was changed.
The bulk of that income goes to very-high-income taxpayers, in part because they have the largest investments and in part because the tax advantage does not apply to retirement accounts, which is where most ordinary Americans have their investments.
But starting in 2013, the wealthy face significant tax increases. And the increases are greater for investment income. It seems likely that the gap in tax rates between the superrich and the very rich may be narrowed.
For earned income, like salaries and bonuses, married couples who make more than $450,000 now face a top marginal tax rate of 39.6 percent, up from 35 percent. That was part of the deal President Obama and Congress reached at the beginning of 2013. That deal allowed the supposedly temporary tax cuts passed during the George W. Bush administration to become permanent for the bulk of taxpayers. It also provided for some tax deductions to be reduced for those with very high incomes.
That no doubt hurt the rich, but it is the increases in taxes on investment income that have caused the most surprise, and distress, for some wealthy people as they filed their tax returns this month.
Under the Affordable Care Act passed in 2010, the Medicare payroll tax increased by 0.9 percentage point in 2013, but only for couples earning more than $250,000 and unmarried taxpayers earning more than $200,000. And unlike the old Medicare tax, the increase applies to investment income, not just to wages.
More important was an additional 3.8 percent Medicare tax on ''net investment income'' for those couples earning more than $250,000. That includes long-term capital gains and qualified dividends on stock, income that until now was taxed at a maximum rate of just 15 percent. But it also includes other income that had been taxed at the same rate as earned income, including rent, royalties, interest and short-term capital gains.
That tax affects a tiny minority of taxpayers; in 2011, 98 percent of tax returns reported adjusted gross income of less than $250,000. But the tax may help to explain the intensity of the anger felt by some people campaigning to repeal President Obama's Affordable Care Act, which subsidizes health insurance premiums for people who could not previously afford to buy insurance.
Reports of people who faced drastically higher premiums or lost health insurance altogether because of the health law have not stood up to close inspection. But there is no doubt that some very wealthy people are paying higher taxes because of it.
The 2013 tax law made the health law tax bill even higher. The long-term capital gains rate was raised to 20 percent for couples who earn more than $450,000. Add in the Medicare tax, and the capital gains rate is 23.8 percent for the rich.
For the first time in memory, the wealthy are confronting a tax rate on some investment income -- like interest and short-term capital gains -- that is higher than the ordinary income rate. Including the Medicare surcharge, the top rate on such income is now 43.4 percent.
For those who believe low capital gains rates are necessary to encourage investment and economic growth, high taxation of investment income is an outrage. If the recent stock market weakness persists, you can be sure that the additional taxes will be blamed.
As it happens, evidence supporting the theory that low capital gains rates are crucial for growth is not easy to come by. The decade of the 1990s was among the best in American history, whether measured by economic growth or stock market profits. For most of that decade, long-term capital gains rates were 28 percent.
In 2003, in one of the great steps to help wealthy investors, the Bush administration and Congress lowered the tax on dividends to match the capital gains rate, 15 percent. The effective rate paid by the superrich dropped to the low 20s from the mid-20s.
In 2007, the year before the Great Recession, the effective tax rate for the superrich fell to 19.7 percent. That was also the year that 18,394 tax returns reporting that much income were filed, a record that has not been equaled since. The average income reported on those returns that year exceeded $30 million, another first. In 2011, the average was about $28 million.
I.R.S. figures show that in most years since dividend tax rates were reduced, the superrich have reported that about half of their income came from tax-advantaged investments. For the very rich the proportion in 2011 was less than 17 percent. That is no doubt a chief reason for the substantial difference in tax rates for the two groups.
Of course, ordinary Americans also are eligible for preferential tax rates on dividends and capital gains, and for most of us they remain at 15 percent. The catch is that few of us have a lot of investments in taxable accounts and therefore derive little benefit from those breaks. In 2011, the average taxpayer earning less than $500,000 received just 2 percent of his or her income from dividends and long-term capital gains. Most of that money went to people earning more than $100,000.
Most ordinary Americans, if they have investments that produce dividends and capital gains, have them in tax-deferred retirement accounts, either individual retirement accounts or 401(k) plans. When they draw out the income from those accounts, they will pay ordinary income tax rates, regardless of whether the profits came from dividends and capital gains.
If Congress ever gets serious about increasing tax revenue enough to pay for the spending bills it passes, the big tax advantage given to unearned income may have to be reduced, if not eliminated. Eliminating it would mean that the private equity executives who manage to pay very low tax rates -- because they classify their salaries as capital gains -- would be taxed like the rest of us. The ''carried interest'' issue would vanish.
This year, that tax advantage has been reduced, even if only for some of the highest-paid Americans. It is a start toward a tax policy that no longer discriminates against people who have to work for a living because they do not have dividend checks to support them.
URL: http://www.nytimes.com/2014/04/18/business/merely-rich-and-superrich-the-tax-gap-is-narrowing.html
LOAD-DATE: April 18, 2014
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GRAPHIC: PHOTO: Signing the Affordable Care Act. It is partly financed by a new tax on investment income, which hits high-income earners hardest. (PHOTOGRAPH BY J. SCOTT APPLEWHITE/ ASSOCIATED PRESS) (B7) CHARTS: Higher Income, Lower Tax Rate: Taxpayers reporting more than $10 million in income pay lower tax rates than do taxpayers reporting $500,000 to $10 million. That is largely because the highest-income returns include a larger proportion of tax-advantaged investment income. (Source: Internal Revenue Service) (B7)
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The New York Times
August 15, 2016 Monday
Late Edition - Final
Health Insurers Use Reviews, Intended to Constrain Rate Jumps, to Justify Them
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 1285 words
WASHINGTON -- After the Affordable Care Act took effect in 2010, it created a review mechanism intended to prevent exorbitant increases in health insurance rates by shaming companies that sought them.
But this summer, insurers are turning that process on its head, using it to highlight the reasons they are losing money under the health care law and their case for raising premiums in 2017.
That has ignited an election-year fight between insurers and consumers, who are complaining bitterly about the double-digit increases being sought across the country.
The conflicts have been on vivid display at hearings in states like Pennsylvania, where Highmark, one of the state's largest insurers, has proposed rate increases averaging 41 percent.
''The health of the citizens of Pennsylvania is worth more than the profits desired by health insurance companies,'' Rose Lynd, 35, of Pittsburgh, testified at a hearing in Harrisburg held late last month by the Pennsylvania insurance commissioner, Teresa D. Miller, a former Obama administration official.
Ms. Lynd, a cancer survivor, said her costs were onerous.
''My premiums are more than $600 a month, which is more than our mortgage payment,'' Ms. Lynd said. ''I am grateful that the Affordable Care Act is here for my family, but I am disappointed by its limitations. All I want is a plan that makes our health care affordable, but it doesn't exist.''
Highmark defended its request by saying it was paying out more in claims than it was receiving in premiums. Jeff Scheib, the vice president in charge of actuarial services at Highmark, offered a statistic to illustrate the problem.
''There were close to 250 individual A.C.A. policyholders in Pennsylvania who incurred over $100,000 each in claims and then canceled coverage before the end of the year,'' Mr. Scheib testified. ''This behavior drives up the cost to insure the entire pool, because people use insurance benefits and then discontinue paying for coverage once their individual health care needs have been temporarily met.''
While state insurance commissioners, who review rates, are trying to balance the needs of consumers and insurers in a turbulent market, insurers have extra leverage this year. At least a dozen nonprofit health insurance cooperatives have collapsed, and several big commercial insurers have decided to cut their losses by limiting their participation in the insurance exchanges, the new marketplaces created under the health law.
The problems threaten to shadow Democrats through Election Day. While Hillary Clinton has vowed to ''defend and expand'' the Affordable Care Act, her Republican opponent in the presidential race, Donald J. Trump, has seized on the issue. At a rally in Fairfield, Conn., on Saturday, he repeated his vow to repeal the health law, saying consumers were facing rate increases greater than they had ever seen.
Ms. Miller, the Pennsylvania commissioner, said that protecting consumers was a top priority. But she said, ''The large requests before me this year are not unique to Pennsylvania, unfortunately.'' Arthur M. Lucker, a consultant to the Pennsylvania Insurance Department, said insurers had requested rate increases of more than 25 percent in at least 20 states, including Arizona, Florida, Ohio and Texas.
Aviva Aron-Dine, an economist at the federal Department of Health and Human Services, said predictable factors were behind the upward pressure on rates. For example, the federal government is ending a program that helped pay some of the largest claims incurred by insurers.
In addition, Ms. Aron-Dine said, some insurers may be trying to make up for having initially set premiums too low. In any event, she said, most people buying insurance on the exchanges receive subsidies.
Connecticut has a state-run insurance exchange considered one of the most successful in the nation. But that has not provided a guarantee of stable rates.
Anthem, for example, is seeking an average increase of 27 percent in Connecticut.
That is ''just off the charts and unacceptable,'' one Anthem customer, Douglas H. Wade Jr. of Bridgeport, said at a hearing in Hartford on Aug. 3.
Matthew McDermott, the leader of an interfaith advocacy group, Congregations Organized for a New Connecticut, said: ''We're concerned that the proposed rate increases will drive many employers and many individuals to drop coverage altogether. And we worry that that heads us toward a market failure here in Connecticut.''
Two of the four insurers on the Connecticut exchange have indicated that they will not be offering plans in that marketplace next year. ''Higher-than-expected health care costs have jeopardized the financial solvency of some insurers and have caused other insurers to leave the exchange altogether,'' said James Augur, a regional vice president of Anthem in Connecticut.
At a hearing in Helena, Mont., Monica J. Lindeen, the state insurance commissioner, asked Blue Cross and Blue Shield why it was seeking an average rate increase of 62 percent for 2017, after receiving an increase of 22 percent this year.
''Cost is what's really driving our rate increases,'' said Michael E. Frank, the president of Blue Cross and Blue Shield of Montana.
''For every dollar we brought in last year, we paid out $1.26 for medical care,'' Mr. Frank said. ''In the first six months of this year, we have already paid $4.17 million in medical costs for the top 10 individuals. That's $70,000 a month for those individuals.''
Insurers invariably cite drug costs as a factor driving up premiums. James Spencer, the chief actuary of Blue Cross and Blue Shield of Montana, said 1 percent of prescriptions accounted for 30 percent of pharmacy costs.
Ms. Lindeen wanted to know why Montana Blue Cross and its parent company, Health Care Service Corporation, had not constrained the pay of top executives. The parent company reported total compensation of more than $11 million for its chief executive in 2014. A Blue Cross executive told Ms. Lindeen that executive pay reflected ''the size and complexity of our business'' and was a tiny share of total expenses.
While the Obama administration has said the federal insurance marketplace is gaining healthier, lower-cost consumers, several insurers said at the hearings that they had not seen a significant improvement.
''Studies concluded that the market would stabilize after absorbing the pent-up demand from the previously uninsured population,'' testified Eric Galvin, the chief financial officer of ConnectiCare Insurance Company. But, he said, ''rather than stabilize, that cost has continued to skyrocket, and we see no end to that higher level of spending.''
Christopher F. Koller, a former health insurance commissioner in Rhode Island, said he was always concerned that insurers were seeking higher rates than necessary, with the expectation that their requests would be cut back by state regulators.
But even if officials trim proposed rates, consumers can still face substantial increases.
This month New York officials approved rate increases averaging 16.6 percent for individual health insurance plans in 2017, more than twice the average in the state for 2016.
The insurance commissioner in Mississippi approved an average rate increase of 43 percent for Humana, fearing that the company might otherwise leave the state's insurance exchange, as UnitedHealth intends to do.
And the Kentucky insurance commissioner has approved increases averaging 5.6 percent for Aetna, 22.9 percent for Anthem and 31 percent for Humana.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
URL: http://www.nytimes.com/2016/08/15/us/politics/health-insurers-use-process-intended-to-curb-rate-increases-to-justify-them.html
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(Fiscal Crisis)
October 16, 2013 Wednesday
House Republicans Gearing Up for Round 2
BYLINE: Ashley Parker
SECTION: US; politics
LENGTH: 477 words
HIGHLIGHT: Coming out of a closed-door meeting Wednesday afternoon, Republican lawmakers are already regrouping for the next fight.
WASHINGTON - Coming out of a closed-door meeting Wednesday afternoon, in which Speaker John A. Boehner explained to his conference that he would be taking up the Senate deal and likely passing it with the help of Democratic votes, Republican lawmakers were already regrouping for the next fight.
"I'll vote against it," Representative John Fleming of Louisiana said. "But that will get us into Round 2. See, we're going to start this all over again."
But the next time around, Republicans are also hoping for a better outcome.
"If we get past tomorrow, we can all take a deep breath and basically refocus - knowing we have January out there - and refocus on trying to get some big things," said Representative Adam Kinzinger of Illinois. "I'm not overly optimistic, but it's a better position than we are today."
Mr. Kinzinger said that Mr. Boehner had delivered a similar message. "Look, we've got move forward here," he said, recounting Mr. Boehner's pitch. "The fight's not over. Everybody knows we're against the health care bill. Now the health care bill is going to be front and center once we get past this, and we can see if it's successful or if it's not, but this isn't the end of the fight."
Earlier in the day, Representative Raul Labrador of Idaho had criticized the Republican leadership team for combining the fight to finance the government - and, later, to reopen the government - with the fight over the debt ceiling. Republicans, he said, were unlikely to stand strong in their efforts to defund the health care law when faced with the risk of potentially devastating debt default.
Now, with the government poised to reopen and default pushed down the road, the hope among Republicans is that they can refocus on the issues most important to them - the effort to chip away at the Affordable Care Act and to enact spending cuts.
" I think there are battles to be had," said Representative Trey Gowdy of South Carolina.
The mood at the meeting was described as upbeat - or at least as positive as could be expected for a group that knew that knew the fight had been lost.
"The speaker did his best to reassure the troops," Representative Blake Farenthold of Texas said. "It's the classic 'we'll live to fight another day.' "
Even the most hard-line conservatives - those who had refused to compromise and pushed their leadership farther to the right - were pleased with Mr. Boehner and his team.
"I'm very proud of our leadership," Mr. Fleming said. "I didn't think they would hang in there two weeks, and so I'm very proud that they did that. So I'm head over heels in jubilee over what they've done, how hard they've tried."
Boehner Supports Deal, but Says G.O.P. 'Fight Will Continue'
Boehner 'Disappointed' by Obama's News Conference
House May Consider Short-Term Financing Measure
House Republicans Look to Vote on New Bill
Collins Says Senate Must Press On
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The New York Times
October 22, 2013 Tuesday
Late Edition - Final
Obama Admits Web Site Flaws On Health Law
BYLINE: By MICHAEL D. SHEAR and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1232 words
WASHINGTON -- President Obama offered an impassioned defense of the Affordable Care Act on Monday, acknowledging the technical failures of the HealthCare.gov Web site, but providing little new information about the problems with the online portal or the efforts by government contractors to fix it.
With Republican critics seizing on the Web site's issues as evidence of deeper flaws in the health care law, Mr. Obama sought to deflect attention from the continuing problems by focusing on ways to get coverage without going online. Like a TV pitchman, the president urged viewers to call the government's toll-free number for health insurance, acknowledging that ''the wait times probably might go up a little bit now.''
In remarks in the Rose Garden, Mr. Obama acknowledged serious technical issues with the Web site, declaring that ''no one is madder than me.'' He offered no new information about how many people have managed to enroll since the online exchanges opened on Oct. 1. And he did not address questions about who, if anyone, might be held responsible for the failure.
The president and his top aides played down the importance of the online marketplace that his administration once heralded as the key to the law's success. Mr. Obama promised that officials are working to fix the Web site, but said that Republican critics should ''stop rooting'' for the failure of a law that provides health insurance to people who do not have it.
''We did not wage this long and contentious battle just around a Web site,'' Mr. Obama told supporters. ''That's not what this was about. We waged this battle to make sure that millions of Americans in the wealthiest nation on earth finally have the same chance to get the same security of affordable, quality health care as anybody else.''
Speaker John A. Boehner said in a statement after the president's event that the administration is ''not prepared to be straight'' with the American people about the issues involving the health care Web site and the insurance program behind it.
''Every day, new questions about the president's health care law arise, but candid explanations are nowhere to be found,'' said Mr. Boehner, of Ohio. ''This decision continues a troubling pattern of this administration seeking to avoid accountability and stonewall the public.''
As they have pushed to repeal or defund Mr. Obama's signature health care law, Republicans have demanded that the administration provide data to show how many -- or how few -- people have enrolled in health insurance plans through the online portal. On Monday, White House officials again refused, saying they plan to offer such numbers in mid-November and monthly after that.
The White House refusal to provide enrollment data stands in contrast to the administration's insistence that states submit detailed weekly reports on the number and characteristics of people who sign up for insurance through state-run exchanges. The Department of Health and Human Services said it needed the data so it could ''track those measures which have the most potential to adversely impact beneficiaries related to their ability to enroll in insurance plans.''
The department said it wanted to shine a spotlight on the performance of state exchanges, which were built with the help of federal money, and it emphasized the importance of ''transparency in the performance of marketplaces.''
Moreover, the administration said that frequent reporting of performance data was needed so federal officials could spot problems with the state exchanges and step in to help fix them. In fact, the state exchanges have generally performed better than the federal exchange.
With many consumers still unable to use the online portal, health policy experts outside the government have begun discussing possible ways to provide relief if the problem continues.
One option is to extend the six-month enrollment period, which is set to end on March 31. Another is to exempt some people from the tax penalties that apply to those who go without insurance in 2014.
Jay Carney, the White House press secretary, suggested that such relief would be unnecessary if the administration fixed the Web site so people could enroll easily in the near future.
Over the weekend, the administration announced a ''tech surge'' that would bring in ''the best and the brightest from both inside and outside government'' to fix the Web site. But on Monday, White House officials declined to answer questions about the contractors who designed HealthCare.gov or to provide the names of the ''experts from some of America's top private-sector tech companies'' that the president said have offered to help the government fix the site.
The White House also declined to comment on a decision by Kathleen Sebelius, the secretary of health and human services, not to testify on Thursday at a hearing by the House Energy and Commerce Committee. Ms. Sebelius has said she will be at a mental health gala at the John F. Kennedy Presidential Library and Museum in Boston that day.
''For specifics about, you know, requests to individual departments and officials who will be made available, I'd refer you to those departments,'' Mr. Carney said. Department of Health and Human Services officials said Ms. Sebelius would make herself available to testify before Congress next week, but Republicans said that was not good enough.
''What is more important to Secretary Sebelius than providing answers to the American people?'' Mr. Boehner asked.
For months, federal health officials had promoted the Web site of the federal exchange as the best place for consumers to compare and buy health insurance plans and obtain financial assistance to help pay premiums. But on Monday, with many users still frustrated by technical problems on the Web site, Mr. Obama emphasized that consumers could also apply for insurance over the phone by calling 800-318-2596.
The home page of the Web site for the federal exchange used to have a single button that said, ''Apply now,'' which began an online application process. The Web site now displays two buttons: ''Apply online'' and ''Apply by phone.''
That message is a turnabout for the administration, which had spent months leading up to the Oct. 1 opening of the marketplaces by saying it would focus on tech-savvy young people.
For the insurance marketplaces to work effectively, they must attract healthy, young people as well as older, sicker people. Officials had assumed that older, uninsured people would be eager to sign up, so the administration developed elaborate plans to woo the younger ones.
Those plans were largely built around getting young people to sign on to the Web site, which Mr. Obama had said would be as easy to use as Amazon.com or other consumer-oriented Web sites. In his remarks on Monday, Mr. Obama made clear that those efforts will have to wait until the Internet portal is working more effectively. He urged young people to be patient and to return to the Web site in the weeks and months ahead.
''Unlike the day after Thanksgiving sales for the latest PlayStation or flat-screen TVs, the insurance plans don't run out,'' Mr. Obama said. ''They're not going to sell out. They'll be available through the marketplace throughout the open enrollment period. The prices that insurers have set will not change. So everybody who wants insurance through the marketplace will get insurance, period.''
URL: http://www.nytimes.com/2013/10/22/us/politics/obama-pushes-health-law-but-concedes-web-site-problems.html
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GRAPHIC: PHOTOS: President Obama spoke Monday in the Rose Garden about the technical problems on the Web site HealthCare.gov, declaring that ''no one is madder than me.''
Kathleen Sebelius, the secretary of health and human services. (PHOTOGRAPHS BY GABRIELLA DEMCZUK/THE NEW YORK TIMES) (A14)
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The New York Times
November 9, 2013 Saturday
Late Edition - Final
Equal Coverage for the Mentally Ill
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 20
LENGTH: 500 words
A struggle over decades to force insurers to cover mental health and addiction services on the same basis as medical and surgical costs is headed for success under new rules issued on Friday by the Obama administration. The rules will cover most Americans with health insurance, including those in many employer-sponsored plans, in other group plans, in some but not all Medicaid plans, and in policies bought on the individual markets.
The rules strengthen a 2008 law that required parity in coverage -- but only when an insurer actually offered mental health and addiction benefits. It did not require such benefits. The new health care law, the Affordable Care Act, does require coverage for mental health and substance abuse as 1 of 10 essential benefits in any new health plans. Combined, the two complete the job of offering both parity and coverage.
What the new rule would mean in practice is that limits on the amount of co-payments and the number of doctor visits or hospital days cannot be less generous than those that apply to most medical and surgical benefits. The same would be true of other rules, like those requiring prior authorization.
The benefits for the American public could be substantial, bringing help to many people previously unable to get it because of the cost. About a quarter of Americans 18 and older have a diagnosable mental disorder in a given year, and 6 percent have a seriously debilitating disorder, according to the National Institute of Mental Health. Nearly 60 percent of the people with mental health conditions and 90 percent of those with substance abuse problems don't get the treatment they need, according to the administration.
The administration hopes that making treatment available to the mentally ill will help reduce gun violence, including mass murders. Some backers of parity believe it will also help veterans suffering from stress disorders from the battlefield get easier access to mental health services.
The effect on costs is uncertain. Insurers fear that the expenses of high-cost inpatient treatment or long-term rehabilitation of patients suffering from mental health disorders or substance abuse will drive up insurance costs, but experts say the number of people receiving high levels of care will be too small to have a significant effect on overall costs. And in the long run, better care could cure enough people to save billions of dollars a year in medical costs, lost wages and reduced productivity associated with alcoholism and other addictions.
Still, it is too early to declare victory. The rules will need to be vigorously enforced by state insurance commissioners who already have their hands full trying to make the Affordable Care Act work. And more money may need to be invested in behavioral health clinics or other providers to meet the demand for services by people who suddenly have insurance to pay the bill. Merely having an insurance policy is no guarantee that a provider can be found to deliver the necessary care.
URL: http://www.nytimes.com/2013/11/09/opinion/equal-coverage-for-the-mentally-ill.html
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The New York Times
June 13, 2012 Wednesday
Late Edition - Final
Romney Uses Obama's Words Against Him, Calling Him 'Out of Touch'
BYLINE: By MICHAEL BARBARO
SECTION: Section A; Column 0; National Desk; THE CAUCUS; Pg. 17
LENGTH: 908 words
ORLANDO, Fla. - Mitt Romney understands the power of the verbal gaffe, real or perceived. During the Republican primaries, he offered up an all-you-can-eat buffet of them: his wife's ''Cadillacs,'' his friends' Nascar teams, how he liked being able to fire people.
Every time, the Obama campaign and its Democratic allies were eager to pounce.
Now, having absorbed the painful lessons of the hyper-magnified (and context-removed) political blunder, Mr. Romney is turning the tables on President Obama.
For the fifth day in a row, the Romney campaign assailed Mr. Obama on Tuesday over remarks that it said revealed his disconnect from economic reality, a theme that began on Friday after the president declared that the ''private sector is doing fine'' and shows no signs of letting up.
In a speech here in Orlando, Mr. Romney seized on a statement that the president made on Monday about the Affordable Care Act.
In an interview, a television reporter had asked the president about a small business in Iowa, whose owner claimed that the president's health care legislation had contributed to its closing in the state. Mr. Obama said that such an assertion of cause and effect was ''kind of hard to explain.''
''Because the only folks that have been impacted in terms of the health care bill are insurance companies who are required to make sure that they're providing preventive care, or they're not dropping your coverage when you get sick,'' Mr. Obama said. ''And so, this particular company probably wouldn't have been impacted by that.''
A gaffe? Mr. Romney treated it that way, and in his speech at a factory that makes air filters, he called the statement ''something else that shows just how much out of touch'' the president is.
''He said he didn't understand that Obamacare was hurting small business,'' Mr. Romney said. ''You have to scratch your head about that.''
Mr. Romney cited an online survey of almost 1,500 small-business owners, performed last July for the U.S. Chamber of Commerce, which found that three-quarters of them said they would be less likely to hire because of the burdens of the Affordable Care Act.
Afterword, a senior adviser to Mr. Romney, Eric Fehrnstrom, said that Mr. Obama's comments about health care showed that ''this is a president who is detached from the effect his policies are having on the economy.''
The charge of being out of touch is as old as politics itself. But it has become clear that the strategy will be deployed with growing regularity by the Romney campaign, allowing it to cast Mr. Obama as an entrenched Washington insider and sidestep potentially nettlesome issues like Mr. Romney's own experience with health care in Massachusetts. Not once during his speech on Tuesday did Mr. Romney discuss his government-sponsored overhaul of that state's health care system.
Instead, Mr. Romney reiterated his plan to replace the Affordable Care Act with what he likened to a ''consumer market.'' That plan would allow those who buy insurance to receive the same tax advantages as businesses that purchase insurance for employees, ensure coverage for those with pre-existing conditions and hand control of health care to states, rather than the federal government.
With the Supreme Court likely to rule soon on the constitutionality of the health care law, Mr. Romney emphasized that his plan would be put into place regardless of the court's decision.
The Romney campaign has a simple message these days, which it is repeating over and over: what it portrays as President Obama's ''mistakes'' are not mistakes at all. Instead, they are windows into the mind of a man detached from the problems of ordinary Americans and small businesses.
It is a striking line of attack that seeks to repurpose and reverse the thrust of Mr. Obama's central critique of Mr. Romney: that he is a rapacious corporate raider unfamiliar with the problems of regular Americans.
That message was at the core of the television commercials that the Obama campaign has run mocking Mr. Romney's tenure at Bain Capital, which feature laid-off workers. And at a fund-raiser in Owings Mills, Md., on Tuesday, Mr. Obama, who plans to give an address on the economy on Thursday, chided his opponent for his barrage of recent attacks.
''Because folks are still hurting right now, the other side feels that it's enough for them to just sit back and say things aren't as good as they should be, and it's Obama's fault,'' the president said. ''I mean, you can pretty much put their campaign on a tweet and have some characters to spare.''
The president's campaign staff said it welcomed a debate over which candidate is more out of touch, especially given Mr. Romney's rhetorical record during the primary. But that is not deterring Mr. Romney. On Tuesday morning, he appeared on ''Fox and Friends,'' where he said the president was ''really out of touch with what is happening across America.''
''The president needs to go out and talk to people, not just do fund-raisers, go out and talk to people in the country and find out what is happening,'' Mr. Romney said.
That criticism appears to be seeping in. At the event here, Frank Attkisson, a small-business consultant and local commissioner, nodded in agreement with Mr. Romney during the speech, and afterword said the president's statements about the private sector and the health care law reveal ''his true colors.''
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com
LOAD-DATE: June 13, 2012
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: The Republican Mitt Romney said the president was disconnected from real Americans during a campaign stop Tuesday. (PHOTOGRAPH BY BRIAN BLANCO FOR THE NEW YORK TIMES)
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The New York Times
September 9, 2014 Tuesday
Late Edition - Final
Health Chief Seeks to Focus on Insurance Site
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 657 words
WASHINGTON -- Sylvia Mathews Burwell, the secretary of Health and Human Services, said Monday in her first major speech that she wanted to move beyond the politics of health care and work with members of both parties to improve the management and operation of HealthCare.gov, the website used by millions of people to sign up for insurance coverage.
''What I've told my team is that we're not here to fight last year's battles,'' she said. ''We're here to fight for affordability, access and quality.''
With midterm elections two months away, Ms. Burwell said she wanted to shift the conversation to areas of potential agreement. Polls consistently show that the public remains more negative than positive on the Affordable Care Act, but that Americans want Congress to improve the law rather than to repeal it.
''The American people are sending a very clear message that they want us to work together on health care,'' Ms. Burwell said, in remarks at George Washington University.
Ms. Burwell said that since she took office in June, she has heard the same message from many people: ''Enough already with the back and forth on the Affordable Care Act. We just want to move forward.''
The next open enrollment period begins Nov. 15 and runs through Feb. 15, half as long as the first sign-up period.
Shortly after Ms. Burwell finished her speech, she announced that the Obama administration was awarding $60 million in grants to 90 organizations that would counsel consumers on health insurance. Such counselors, also known as navigators, were indispensable in helping consumers use balky federal and state websites in the first enrollment period, which ran from October of last year through March of this year.
Last year the government awarded $67 million in navigator grants to 105 organizations, many of which had subcontractors.
The Obama administration said it would require all navigators to take additional training courses and be recertified if they wanted to advise consumers in the coming open enrollment period. The new curriculum includes courses on how to verify a person's immigration status, how to count household income and how to help college-age students enroll in coverage.
Among the larger new recipients of grants are the University of South Florida, which is receiving $5.4 million for a statewide consortium of 12 organizations; United Way of Tarrant County, serving the Fort Worth area ($4.6 million); Legal Aid of North Carolina ($2.3 million); and the Ohio Association of Foodbanks ($2.2 million).
Smaller grant recipients include the Arab Community Center for Economic and Social Services, in Dearborn, Mich.; Planned Parenthood organizations in Iowa and Montana; the Beaufort County Black Chamber of Commerce in South Carolina; and Primero Health, a Latino community organization in Texas.
In her remarks, Ms. Burwell drew implicit contrasts with her predecessor, Kathleen Sebelius, who supervised the disastrous debut of the health care website last fall. Ms. Burwell repeatedly emphasized her management skills, honed as president of the Walmart Foundation and as director of the White House Office of Management and Budget under President Obama.
Ms. Burwell promised a new era of transparency and candor, and said her goal was to answer letters from Congress within 30 days. But in response to questions, health officials said they were unable to update the enrollment figures issued on May 1, when they reported that eight million people had signed up for private insurance through the federal and state marketplaces.
Within hours of Ms. Burwell's speech, Republican leaders of the House Energy and Commerce Committee sent her a letter demanding detailed information on state-run exchanges that experienced severe problems. The lawmakers first requested the information in early June.
Five of those states -- Hawaii, Maryland, Massachusetts, Minnesota and Oregon -- received a total of more than $1 billion in federal grants.
URL: http://www.nytimes.com/2014/09/09/us/politics/healthcaregov-upgrades-are-priority-for-new-health-and-human-services-chief.html
LOAD-DATE: September 9, 2014
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: Sylvia Mathews Burwell, the secretary of Health and Human Services, shown in May. (PHOTOGRAPH BY J. SCOTT APPLEWHITE/ASSOCIATED PRESS)
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The New York Times Blogs
(You're the Boss)
March 26, 2014 Wednesday
Why Employers Will Stop Offering Health Insurance
SECTION: BUSINESS; smallbusiness
LENGTH: 1356 words
HIGHLIGHT: Dr. Ezekiel J. Emanuel makes the case that freeing employers from the burdens of providing health insurance is a good thing.
Here's a prediction: By 2025, "fewer than 20 percent of workers in the private sector will receive traditional employer-sponsored health insurance." The source of this claim? Dr. Ezekiel J. Emanuel, in his just-published book, "Reinventing American Health Care."
Dr. Emanuel is an accomplished oncologist, medical ethicist and academic (and contributing opinion writer to The New York Times). And, of course, he's no stranger to politics: He helped craft the Affordable Care Act as a health policy adviser to the Obama administration, when his brother, Rahm, now the mayor of Chicago, was chief of staff. The book is a full-throated defense of the law (its subtitle: "How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System").
In it, Mr. Emanuel argues that in the next two or three years, "a few big, blue-chip companies will announce their intention to stop providing health insurance. Instead, they will raise salaries substantially or offer large, defined contributions to their workers. Then the floodgates will open." He says that few small businesses will join the SHOP exchanges set up for them and that most of those that offer coverage are even more likely than big companies to drop it, since those who employ fewer than 50 workers face no mandate to offer it in the first place, which Mr. Emanuel thinks is fine.
Mr. Emanuel acknowledges that the fact that worker's don't pay taxes on the premium benefit from their employers is a big obstacle to this vision - the tax break is the second-biggest deduction in the tax code, and employees won't be eager to give it up. But, he argues, the so-called Cadillac tax on especially generous health plans, set to take effect in 2018, will help pave the way by discouraging companies from offering those plans.
In two conversations that have been condensed and edited, Mr. Emanuel walked us through his prediction and talked about other aspects of the health law's impact on businesses small and large - and then conceded that he could well turn out to be wrong.
Q.
You say that employers will stop offering insurance by 2025. Why do you think that's a good thing?
A.
I have a different view than many people. I think that if you have good options in the exchange, and a lot of competition to keep prices down, I think a good marketplace could work well. But a lot of people like their employer giving it to them, and I think a lot of people are uncertain about what the new world will offer.
Q.
What will causes employers to stop offering insurance?
A.
Why does an employer do it now, when there's no mandate, no requirement? Because it needs to attract workers, and workers have no real other options. The individual market is not enough of an alternative. The first and most important, essential, requirement is that the exchanges work well, become a positively branded experience, and give people a lot of choice - choice that they like.
Q.
Do you think that's going to happen - especially given the way the rollout took place?
A.
I'm driving back from having visited the Connecticut exchange - yeah, I think it can happen. The Connecticut exchange has arguably been the best exchange, but nothing they do is rocket science. It's like running an e-commerce site focused relentlessly on a better customer experience and making sure things go well. They want to get down to 30-minute shopping. And I think if you've got exchanges that are working in that frame of mind, I think, yes, it's possible.
Q.
So an alternative is in place. What then makes employers conclude they don't want to provide insurance?
A.
Some of them will continue. They'll say, "A good employer provides insurance, takes care of its workers, cares about its workers, and this is one way we communicate it." Others will say, "It's better for my employees to drop coverage. They have freedom to decide how much they want to spend on health care. They have more choices than I can offer, and I would prefer not to spend the money, resources, time doing the insurance - I can give them the defined contribution, I'll know what the costs are year to year - it's very predictable." And the exchange is a good place. People actually like it. It's not looked at as, "Wow, they're abandoning me."
Q.
Won't losing the tax break on the coverage be painful for middle-class employees who make too much to qualify for subsidies?
A.
Well, there may be ways of their employer not providing them insurance but providing them a way to get insurance that allows them to keep the tax exclusion. You have to go into the innards of what it means for the employer to sponsor the insurance. But I'm sure they've got a lot of lawyers working on it.
Q.
There has been a perception that the rollout of the Affordable Care Act has been more difficult for small businesses than it was supposed to be - even businesses that aren't subject to the mandate worry their costs will go up.
A.
One of the problems we have here is that human beings have short memories. It was not an easy market for most people before the A.C.A. Rates were very volatile - if you're a small business and one person gets sick, your rates the following year are really subject to increases. I don't think people were by and large happy with it. And so to complain about the A.C.A. seems to me to be not fair.
Q.
Do you think that the Obama administration wanted to get companies away from coverage?
A.
No! I didn't actually think this through. I don't think anyone thought it through. Look, we relied on Massachusetts, where there was crowd-in - more employers began offering coverage. So that was the thinking: More people will offer coverage.
Q.
You say in your book that Massachusetts hasn't been able to set up a vibrant SHOP exchange. What's the problem with the SHOP exchanges?
A.
I've always been a bit perplexed by the idea of setting up a SHOP exchange, since I don't understand why it's just not better if you're a small business to say, all right, everyone, I'm just going to give you X amount of dollars and let you shop in the individual market. That seems to me to be a way to go - why should a small business set up a lot of machinery around it? Why should exchanges set up a lot of machinery? And it would be better for exchanges to have these workers in the individual exchange.
Q.
Doesn't it come down to that basic comfort level that people have - they are used to getting their insurance from their small-business employer.
A.
Right. We're creatures of habit, and once we've gotten the habit, it may be that people will prefer that habit. Look, the best argument against me, and against my prediction, is Massachusetts. Lots of big in-state employers have continued to offer insurance, and as a matter of fact what has happened in Massachusetts is more employers have offered insurance because their workers say, "Look, there's a mandate, you've got to give it to me."
That's the danger of making predictions. The best example we have says that Emanuel is wrong on all counts when it comes to this, and I don't have a counterargument. I have my predictions, but there's no evidence for mine that's as strong as the Massachusetts evidence.
Q.
Should there be any employer mandate to provide insurance? Some people argue that it's a marginal policy at best.
A.
I think that the mandate or a penalty for larger businesses is the right thing to do. They should pay their fair share.
Q.
But it makes it harder for them to exit.
A.
Exactly. That's another argument against me, which is $2,000 an employee is not so easy to do. That's real money to them, but obviously if they exit and they put people into the exchange, and many of those people get subsidies, someone's going to have to pay for it.
The I.R.S.'s Final Mandate Reporting Rules? Still Complicated
Study Indicates That Bill Redefining Full-Time Employment Would Have Costs
Why Most Small-Business Owners Will See Premiums Rise Under A.C.A.
Assessing Who Benefits From the Latest Rulings on the Employer Mandate
A Hotelier Corrects His Testimony on the Impact of the Affordable Care Act
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The New York Times
December 24, 2013 Tuesday
Late Edition - Final
Day Is Added To Deadline As Rush Hits Health Portal
BYLINE: By MICHAEL D. SHEAR and ROBERT PEAR; Ashley Parker contributed reporting from Honolulu, and Katie Thomas from New York.
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1051 words
WASHINGTON -- A record-setting crush of last-minute shoppers descended on HealthCare.gov on Monday, creating long wait times for users and putting new stress on the government's much-maligned health portal as they raced against a midnight deadline to sign up for coverage that will go into effect on Jan. 1.
More than one million people had logged on to the site by 5 p.m., officials said, five times more than the previous Monday. The flood of visitors quickly triggered a backup queuing system that invites users to come back during less busy times. More than 60,000 people provided an email address on Monday to get invitations to return, officials said.
The high volume of visitors also prompted White House officials to abruptly establish a 24-hour grace period that will effectively extend the deadline, allowing those who sign up on Tuesday to still receive coverage from Jan. 1.
Officials compared the last-minute decision to the kind often made by election officials to keep a polling place open late into the night to accommodate voters already in line at closing.
The grace period was the latest example of the administration's willingness to fiddle with deadlines that once seemed set in political concrete. The botched rollout of the website has forced the White House to adjust its plans repeatedly in an attempt to accommodate users and avoid further examples of signs that the program is not ready for prime time.
''We have taken steps to make sure that those who tried to enroll today, but had delays due to high traffic, have a fail-safe,'' said Julie Bataille, a spokeswoman for the federal Centers for Medicare and Medicaid Services.
''People are having a really difficult time getting through,'' David Oscar, an insurance broker in Fairfield, N.J., said Monday. He said frustrated clients were calling to say the website was sluggish. ''My phone has been burning up. It's the worst time of year to start this, and all these people who need coverage have so many other things that they're doing.''
Even so, administration officials said there would be no more extensions. After Tuesday, people who sign up for insurance through HealthCare.gov should not expect to have coverage at the beginning of 2014, they said.
President Obama's aides are bracing for Republicans to seize on stories of people whose insurance was canceled because of the Affordable Care Act and who were unable to find a replacement by Jan. 1. Some of those people may appear at a hospital, a doctor's office or a pharmacy and be told that they no longer have coverage.
''While the holiday surprises have become commonplace, the latest extension is another disappointment for the 'most transparent administration in history,' '' Representative Fred Upton, Republican of Michigan, the chairman of the House Energy and Commerce Committee, said in a statement. ''As we celebrate Christmas and prepare to ring in the new year, we continue to ask, what's next?''
Mr. Obama, vacationing in Hawaii with his family, offered a symbolic gesture to people who are using the government's health care site to get insurance: White House officials announced Monday that the president had enrolled in a health insurance plan over the weekend by using the District of Columbia's website.
The president and his family receive health care through the military. But administration officials said they hoped that Mr. Obama's gesture would set an example for many of the uninsured they were urging to sign up before the deadline.
Even though Mr. Obama will not actually use his new plan, a White House official said, ''he was pleased to participate in a plan as a show of support for these marketplaces, which are providing quality, affordable health care options to more than a million people.''
The president opted for a bronze plan, one of the less expensive options on the HealthCare.gov site.
For many ordinary visitors who had postponed visiting the health care website, Monday was a frustrating day. While it appeared that the site did not crash or go offline, people calling the federal exchange on Monday morning were greeted with a recorded message: ''Welcome to the health insurance marketplace. We are currently experiencing longer-than-normal hold time. Do you need coverage for Jan. 1? Please stay on the line, as your call is important to us.''
Callers were told to be prepared for a long wait. ''If you are using a cell- or cordless phone, make sure it's fully charged,'' the message said. In the early evening, some were told that they would have to wait 30 minutes. Others heard a recorded message that said: ''Due to heavy call volumes, we are unable to take your call at this time.''
Robert E. Zirkelbach, a spokesman for America's Health Insurance Plans, a trade group, said insurers would ''do everything they can to help consumers through the enrollment process and mitigate potential confusion or disruption caused by all of these last-minute changes to the rules and deadlines.''
He said insurers voluntarily extended a separate payment deadline last week. Consumers must pay the first month's premium before coverage takes effect, he said, but those who pay by Jan. 10 will be able to have coverage retroactive to Jan. 1.
Shaun Greene, the chief operating officer at Arches Health Plan, a co-op in Utah, said the news that the deadline would be extended had sent him scrambling for volunteers to staff phones, since he had promised his regular employees that they would get Christmas Eve off.
''We've got a good team down here who's worked hard for us,'' Mr. Greene said. ''We're not going to strong-arm them into working.''
Suzy K. Johnson, who is president of Employee Benefit Advisors, an insurance brokerage firm in North Carolina, said HealthCare.gov had been working smoothly for her clients. ''The website is working, and many are getting significant subsidies,'' she said. By midday, she said, her office had helped six people sign up for coverage.
The shift in Monday's deadline surprised insurers and many federal health officials. A senior official at the Center for Consumer Information and Insurance Oversight, the office that runs the federal exchange, said in the early afternoon that he and his colleagues had not been formally advised of the change -- even though the White House had confirmed it several hours earlier.
URL: http://www.nytimes.com/2013/12/24/us/deadline-for-health-care-sign-up-is-extended-by-a-day.html
LOAD-DATE: December 24, 2013
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: An enrollment specialist in Miami, Laquanda Jordan, helped Narendra Parmar sign up for insurance under the Affordable Care Act on Monday. A deadline was extended to Tuesday. (PHOTOGRAPH BY JOE RAEDLE/GETTY IMAGES)
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The New York Times
May 17, 2016 Tuesday
Late Edition - Final
Health Law Challenge May Raise Rates
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 908 words
WASHINGTON -- Victory for House Republicans in federal court last week could mean significantly higher health insurance premiums for millions of people if the decision is upheld on appeal, the Obama administration said Monday.
And much of the cost for those higher premiums could be passed on to the federal government and taxpayers, administration officials and health policy experts said.
The ruling by Judge Rosemary M. Collyer of the United States District Court for the District of Columbia would block the administration from reimbursing insurers for discounts provided to millions of low-income people under the Affordable Care Act. Without that money, insurers would have to increase premiums for many people purchasing insurance through the health law's online marketplaces, the administration said.
Judge Collyer said that the administration had paid billions of dollars to insurers since January 2014 even though Congress had not appropriated money for those subsidies, a violation of Article I of the Constitution, which states, ''No money shall be drawn from the Treasury, but in consequence of appropriations made by law.''
The disputed money compensates insurers for the discounts, which make health care more affordable to consumers by reducing co-payments, deductibles and other out-of-pocket costs. If insurers are not reimbursed for the discounts, the administration said, they will need to charge higher premiums to cover their expenses.
A study by the Department of Health and Human Services estimated that premiums for midlevel ''silver plans'' could rise by nearly 30 percent without those reimbursements.
Many consumers would be protected, since under the law, they would be entitled to larger tax credits to help pay the higher premiums, the administration said. However, taxpayers would bear some of the extra costs. The Urban Institute, a nonprofit research organization, estimated additional spending would total $3.6 billion in 2016 and $47 billion over the next decade.
The administration plans to appeal the decision in the case, House of Representatives v. Burwell. The judge held off putting her decision into effect to allow for an appeal.
Clare Krusing, a spokeswoman for America's Health Insurance Plans, a trade group, said: ''We have a long judicial process ahead of us, so there'll be no immediate change to anyone's current benefit. But if you eliminate the cost-sharing subsidies, it would certainly increase the overall cost of coverage.''
Federal officials say the Affordable Care Act gave them permanent authority to help pay deductibles, co-payments and other out-of-pocket costs for certain low-income people who buy insurance through the new public marketplaces. The Congressional Budget Office estimated that these payments, known as cost-sharing reductions, would total $130 billion over the next 10 years.
But if insurers must rely on Congress to provide the money through annual appropriations, that would cause uncertainty in insurance markets, the administration said, noting that Congress was often late in passing bills to finance operations of the federal government.
In court papers, the Obama administration made this forecast: ''If cost-sharing reduction payments were dependent on annual appropriations, insurers would be forced to set their premiums for the upcoming year in the face of uncertainty about the existence and amount of payments they would receive. That uncertainty would be inefficient and destabilizing. It would also inevitably lead to increased premiums.''
Josh Earnest, the White House press secretary, said he felt sure that the administration would ultimately prevail in court. Republicans will ''stop at nothing to try to tear this bill down,'' he said, ''but I continue to be confident that they're going to continue to fail.''
Administration officials said the ruling should not affect 2017 premiums.
The White House contends that the health care law, signed by President Obama in 2010, provides all the authority he needs to pay insurance companies for the discounts they give consumers. But in April 2013, Mr. Obama sought explicit authority, asking Congress to provide the money in one of the annual appropriations bills for 2014. Congress did not act on the request.
''Congress authorized reduced cost-sharing but did not appropriate moneys for it, in the fiscal year 2014 budget or since,'' Judge Collyer said. ''Congress is the only source for such an appropriation, and no public money can be spent without one.''
Nearly five million people, or 56 percent of those enrolled in health plans through federal and state marketplaces, were benefiting from cost-sharing reductions at the end of last year, the administration said.
Researchers at the Urban Institute also predicted that insurers would increase premiums for silver plans if they were no longer reimbursed for cost-sharing reductions. Premiums for such plans, they said, would increase about $1,040 a year per person, or 29 percent.
''If insurers have enough time to develop new rates, they could incorporate the increased costs into the premiums for silver plans,'' said Linda J. Blumberg, a health economist at the Urban Institute. ''But this takes time. You can't change the rules in the middle of the year and adjust prices the next week.''
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URL: http://www.nytimes.com/2016/05/17/us/politics/house-challenge-to-health-law-could-raise-premiums-administration-says.html
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The New York Times Blogs
(The Caucus)
June 28, 2012 Thursday
Obama Heard Mixed Messages on Health Ruling, Too
BYLINE: MARK LANDLER
SECTION: US; politics
LENGTH: 165 words
HIGHLIGHT: President Obama initially heard that the Supreme Court had overturned a key plank of his landmark health-care act.
President Obama initially heard that the Supreme Court had overturned a crucial plank of his landmark health care act before the White House counsel, Kathy Ruemmler, flashed the president a two-thumbs-up sign to indicate it had actually been upheld.
Shortly after 10 a.m., senior administration officials said, Mr. Obama stopped before a bank of four television screens next to the Oval Office that were carrying live coverage from the Supreme Court. Two of the four networks, CNN and Fox News, wrongly reported that the court had struck down the individual mandate as unconstitutional.
Mr. Obama, one official said, was absorbing the news with a quizzical expression. Jack Lew, the White House chief of staff, stood next to him. When Ms. Ruemmler told the president that the court had upheld the law in a 5-to-4 vote, he broke out in a broad smile and gave her a hug. The two cable networks continued with the incorrect reports, though with the sound turned off, Mr. Obama paid no attention.
LOAD-DATE: June 28, 2012
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The New York Times Blogs
(Bucks)
March 20, 2012 Tuesday
Many Americans Struggling to Pay Medical Bills
BYLINE: ANN CARRNS
SECTION: YOUR-MONEY
LENGTH: 273 words
HIGHLIGHT: Roughly a third of Americans are burdened by medical costs, a Centers for Disease Control and Prevention study finds.
All eyes will be on the United States Supreme Court next week as it hears arguments in the challenge to the Affordable Care Act. But while debate over health care reform swirls in the political arena, roughly a third of Americans are in families struggling in some way to pay medical bills, a recent study finds.
The study on the financial burdenof medical care, published by the federal Centers for Disease Control and Prevention, is based on responses to the National Health Interview Survey for the first six months of 2011. The study is based on personal interviews with more than 52,000 people.
The findings aren't too surprising, considering that other recent research finds that the proportion of Americans with health insurance fell during the recent recession.
The C.D.C. analysis found that about a quarter of children age 17 and under were in families struggling to pay medical bills. The likelihood of being in a household unable to pay bills decreased with age, the study found. Just 7 percent of adults age 75 and over were members of such families.
The survey asked participants about whether they had problems paying any medical bills over the last 12 months, whether they were paying any medical bills over time and if they had any medical bills they were unable to pay.
Have you had trouble paying medical bills recently? How are you planning to handle the costs?
Cost of Long-Term Care Insurance Keeps Rising
Rising Health Costs Are a Top Financial Concern of the Affluent
Will High-Deductible Health Insurance Plans Become the Norm?
Medical Debt Cited More Often in Bankruptcies
Can a New Form Make Health Insurance Decisions Easier?
LOAD-DATE: March 22, 2012
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The New York Times
January 29, 2015 Thursday
Late Edition - Final
How the New Health Law Failed to Simplify Medicaid
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; THE NEW HEALTH CARE; Pg. 3
LENGTH: 1208 words
The Affordable Care Act was supposed to simplify Medicaid's myriad programs across the country to provide a more uniform medical safety net for poor Americans in every state.
It hasn't worked out that way. In fact, Medicaid programs now vary more widely state to state and even within states than they did before. Some states have scaled back their Medicaid programs, while others have expanded to new groups of people. Among those that have expanded, many are pursuing new policy experiments instead of expanding their existing programs. This may result in confusion -- for administrators and clients alike.
Indiana has become the latest Republican-led state to expand its Medicaid program as part of the Affordable Care Act. As has become the pattern, it was done with a series of waivers from particular federal requirements. Beginning next week, anyone in Indiana earning less than around $16,000 a year can sign up for the government health insurance program.
When the state's governor, Mike Pence, announced the news on Tuesday, the focus of his speech was less about his state's decision to embrace this part of Obamacare than about the special concessions he'd been able to extract from the Obama administration.
Newly eligible Medicaid recipients will have to pay monthly premiums or be locked out of certain services, he announced, and higher-earning beneficiaries who fail to pay will be shut out of the program for six months. People who use the emergency room frequently will need to pay higher co-payments than the federal government has ever allowed.
The provisions, designed to encourage residents to take more responsibility for the costs of their health care, break new ground in what the Obama administration will allow in exchange for expansion. But they are also the latest in a series of waivers the federal government has negotiated with states in exchange for their embrace of Medicaid expansion.
In Arkansas, new Medicaid recipients buy commercial health plans on the state insurance marketplace, instead of receiving government coverage. Iowans can use Medicaid money to pay for employer plans. Pennsylvanians above a certain income must pay premiums for Medicaid benefits. It's done in the name of experimentation, and one result is that it's a complicated system.
The Medicaid program was designed as a federal-state partnership, and it has always included provisions that allow a high degree of flexibility for states. Though every state participating in the program must follow certain rules and cover certain groups, there have been options for states that want to do more than the minimum. States have also always been allowed to apply for waivers from many of the usual rules to conduct demonstration projects that test theories about cost and how best to care for Medicaid patients.
Before the Affordable Care Act, state programs varied tremendously in whom they covered, what medical services they offered, and who provided Medicaid's health insurance. Medicaid experts liked to joke that if you knew one Medicaid program, you knew one Medicaid program -- and there were more than 50 of them.
A major objective of the health law was to smooth out many of those inconsistencies. The federal government would pick up the bulk of the new Medicaid bill, and in exchange, states would expand their programs to every resident earning below a certain income threshold, this year about $16,000 for a person. All of those people would be covered with plans that included a minimum number of benefits. But, in practice, that hoped-for uniformity has not come to pass.
The Indiana plan, for instance, now includes at least six different categories of adult Medicaid recipients, according to Joan Alker, the executive director of the Georgetown University Center for Children and Families. Each category of beneficiary will have different benefits, premiums and co-payment responsibilities. And that's just in one state.
The Supreme Court blew a hole in the plan to standardize Medicaid when it ruled in 2012 that the federal government couldn't force the states to expand as a condition of staying in the program. The decision gave the states a choice: expand if you wish, or keep the version of Medicaid you had before the health law passed.
The ability to simply sit out the Medicaid expansion -- denying the Obama administration a victory and limiting poor residents' access to health coverage -- has given governors leverage to bargain on just what kind of Medicaid program they want. In Republican-led states, that has meant requests for policies that include privatization and work requirements -- and a desire to brand the expanded coverage as anything-but-Medicaid. (Mr. Pence's plan, for example, is called the ''Healthy Indiana Plan 2.0.'')
Those interested in policy experimentation around health insurance have applauded the new flexibility. The recent waivers have been particularly welcome news to conservative governors and legislators, who think that even the poorest Americans should share in the financial stakes of their health care coverage.
The Indiana experiment in co-payments is designed to test whether asking frequent emergency room visitors to pay a higher fee will encourage them to avoid the E.R. when a doctor's visit might do. If it works, it could save the federal government money, and serve as a lesson to other states. Mr. Pence told my colleague Abby Goodnough that charging the premiums, priced at 2 percent of beneficiaries' incomes, ''gives Hoosiers the dignity to pay for their own health insurance.''
But advocates for Medicaid beneficiaries worry that the added complexities of the new programs -- with premiums and co-payments and other requirements -- will be a burden for the program's poor beneficiaries, and a hassle for state officials and medical providers to oversee. ''It's hard to imagine feeling nostalgic for Medicaid as an administratively simple program,'' Ms. Alker said. ''But I'm beginning to feel that way.''
Some people have argued that managing all the rules and collecting premiums and payments may cost a state more money than it will earn. And there are studies that show that premiums, in particular, tend to discourage low-income people from signing up for coverage and seeking the care they need.
Laura Dague, an assistant professor of health economics at Texas A&M, has studied the effect of small premiums in the Wisconsin Medicaid program. She found that the existence of premiums led to a measurable drop in enrollment. ''There's also a lot of evidence that increasing administrative burden in Medicaid decreases enrollment,'' she said. ''And you could describe a $1 premium as an administrative burden as opposed to a price, because you're not paying any of your costs.''
The coming years will be fruitful for researchers, who can compare the many approaches to the expansion in a search for the best ways to provide health insurance to the poor. But it is a different future than the one that congressional Democrats envisioned when they designed the Affordable Care Act.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our weekly newsletter here.
URL: http://www.nytimes.com/2015/01/29/upshot/the-goal-was-simplicity-instead-theres-a-many-headed-medicaid.html
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December 31, 2013 Tuesday
Late Edition - Final
Second Official to Leave After Health Site Trouble
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 747 words
WASHINGTON -- The No. 2 official at the Centers for Medicare and Medicaid Services, who supervised the troubled rollout of President Obama's health care law, is retiring, administration officials said Monday.
The official, Michelle Snyder, is the agency's chief operating officer. She is the second administration official to depart since problems at the website, HealthCare.gov, frustrated millions of people trying to buy insurance and caused political embarrassment to President Obama.
Ms. Snyder is in charge of the Medicare agency's day-to-day activities and the allocation of resources, including budget and personnel. Technology experts who built the website for the federal insurance exchange reported to her, and she has been actively involved in the effort to fix the site's problems.
Ms. Snyder's departure follows that of the agency's chief information officer, Tony Trenkle, who stepped down in November to take a job in the private sector.
A former agency official who had predicted Ms. Snyder's departure said Monday: ''She had to go. She was responsible for the implementation of Obamacare. She controlled all the resources to get it done. She was in charge of information technology. She controlled personnel and budget.''
Asked about Ms. Snyder's plans, an agency official said Monday: ''It's her personal decision to retire now.''
Ms. Snyder could not be reached for comment.
The move comes after a series of congressional oversight hearings at which Republicans and Democrats sought to determine who should be held accountable for the health law's disastrous rollout. At one such hearing on Oct. 30, Kathleen Sebelius, the secretary of health and human services, was asked who was responsible for developing the federal website, and she named Ms. Snyder. But Ms. Sebelius quickly added: ''Michelle Snyder is not responsible for those debacles. Hold me accountable for the debacle. I'm responsible.''
Ms. Snyder's official biography states that she was responsible for setting up ''new programs and activities required by the Affordable Care Act.''
In an email to agency employees, Marilyn B. Tavenner, the administrator of the Medicare agency, said Ms. Snyder was retiring this week ''after 41 years of outstanding public service,'' but made no mention of her role overseeing the development of the federal insurance exchange.
''While we celebrate her distinguished career, we are also sadly saying farewell to a good friend and a key member of the agency's leadership team,'' Ms. Tavenner wrote. ''Michelle's intelligence, experience and formidable work ethic have been indispensable to me and to many of you during her tenure.''
Ms. Tavenner said that Ms. Snyder was prepared to step down at the end of 2012, but stayed on the job ''at my request to help me with the challenges facing C.M.S. in 2013.''
The agency, which runs Medicare and Medicaid in addition to carrying out major provisions of the Affordable Care Act, provides health insurance to more than 100 million people and spends more than $800 billion a year, which is substantially more than the Defense Department budget.
Agency officials said that Ms. Snyder's deputy, Tim Love, would fill her position on an acting basis.
Many of the initial problems with the federal insurance exchange have been fixed, but their effects linger as the agency and insurers try to correct enrollment records.
In late September, Ms. Snyder signed an internal memo acknowledging that security controls for the website had not been fully tested and recommending a plan to reduce the risks.
Representative Darrell Issa, a Republican of California and chairman of the House Committee on Oversight and Government Reform, said: ''Documents and interviews indicate Michelle Snyder's involvement in bypassing the recommendation of C.M.S.'s top security expert, who recommended delaying the launch of HealthCare.gov.''
However, Patti Unruh, a spokeswoman for the Medicare agency, said: ''There have been no successful security attacks on HealthCare.gov, and no person or group has maliciously accessed personally identifiable information.''
Ms. Snyder became the first chief financial officer of the agency in the late 1990s. In August, she signed a document approving a contract worth up to $11.6 million for ''urgently needed financial management services'' at the new insurance exchanges. The document said the government did not have time to allow competitive bidding because it had just discovered that it needed more financial expertise.
URL: http://www.nytimes.com/2013/12/31/us/politics/official-who-oversaw-health-laws-rollout-is-retiring.html
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The New York Times
January 31, 2017 Tuesday
Late Edition - Final
A Republican Plan for Medicare Is Experiencing a Revival
BYLINE: By AARON E. CARROLL and AUSTIN FRAKT.
Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage. Follow him on Twitter at @aaronecarroll. Austin Frakt is a health economist with several governmental and academic affiliations. He also blogs at The Incidental Economist, and you can follow him on Twitter at @afrakt.
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A number of Republican health care policy proposals that seemed out of favor in the Obama era are now being given new life. One of these involves Medicare, the government health insurance program primarily for older Americans, and is known as premium support.
Right now, the federal government subsidizes Medicare premiums -- those of the traditional program, as well as private plan alternatives that participate in Medicare Advantage. The subsidies are established so that they grow at the rate of overall per enrollee Medicare spending. No matter what Medicare costs, older Americans can be sure that the government will cover a certain percentage of it. That's the main thing that panics fiscal conservatives, because that costs the government more each year.
Premium support could quiet that fear. Subsidies would be calculated so they don't grow as quickly, thus protecting the federal government (that is, taxpayers) from runaway spending. There are lots of variants, but there are really two principal ideas.
The first is to set the subsidy to a level established by the market, as opposed to one established by the government, as it is now.
One way to do that is to tie the subsidy to the average premium of all Medicare plans, including that of traditional Medicare. This is how the Medicare drug program, Part D, already works. For Part D, Medicare collects bids from all plans that reflect their costs of providing the required, minimum level of drug coverage. Then it sets the subsidy at 74.5 percent of the average bid.
Beneficiaries pay the difference, which will be higher for more costly plans that may offer more generous benefits, and lower for cheaper plans. The system also includes additional subsidies for low-income beneficiaries.
The thinking is that the market drives the subsidy. Because insurance companies want to attract more enrollees, they are motivated to drive their bids downward, driving subsidies downward as well and saving taxpayers money.
If this sounds somewhat similar to how the subsidies for the Affordable Care Act marketplace plans work, it's because it is similar. Obamacare ties the premium subsidy to the second-lowest premium instead of the average. If an enrollee wants a plan with more benefits but at a higher premium, he or she would pay the difference, not the government.
But even though the approach is similar to Part D -- which was passed by a Republican Congress and signed into law by a Republican president -- and the A.C.A. marketplaces -- established with only Democratic support -- it does not have bipartisan endorsement.
That's just one more example of how congressional actions and attitudes on health care reform are inconsistent. Republicans think subsidies based on bids is an excellent way to reform Medicare, but they don't laud the Affordable Care Act for adopting the same approach. When it comes to the A.C.A., of course, Democrats supported this mechanism, but they've opposed it when it comes to Medicare reform.
Obamacare's creation of the insurance exchanges and subsidies to expand coverage was a move leftward, supported by Democrats and opposed by Republicans. Anything that relies more heavily on private Medicare options would be a move rightward, and it would probably be opposed by Democrats and supported by Republicans. Such is Washington.
It's worth noting that progressives are also concerned that this plan might erode traditional Medicare. It could do that because, for a variety of reasons, private plans are likely to bid lower than traditional Medicare. If people have to pay more for traditional Medicare, relative to private plans, they're likely to leave it, weakening that arm of the program.
The second main idea included in some premium support plans is to further protect the government from rapidly growing expenditures by explicitly capping the growth in subsidies. This could be layered on top of the bidding approach. It would work like this: Plans bid, and the government picks the average or second lowest. Then the government makes sure it doesn't pay a predetermined amount more than last year -- a growth cap.
This kind of cap on subsidy growth is an even more contentious issue. As anyone who follows health care spending knows, it has grown significantly faster than inflation for the past several decades. Putting a more restrictive cap on growth will make budget projections look better. The problem is that such action assumes that there are ways we haven't previously figured out to reduce Medicare spending without reducing benefits, reducing reimbursement or increasing cost-sharing.
Progressives fear that, given our inability to control health care spending in other ways, this would most likely wind up transferring more and more of the cost of health care onto older Americans themselves. Many would be unable to afford care. The same problems we're seeing with underinsurance and cost-related access barriers in the private insurance market could become more prevalent.
The entire point of premium support is to rely on the market to innovate and come up with more efficient ways of providing health care and health insurance for it. As such, one cannot say in advance how it would keep costs below a growth cap.
Some people deride this as ''market magic,'' and it's easy to see where they're coming from. It's not crazy, however, to think that care could be better managed to produce good outcomes more efficiently, at least to some extent. This, in fact, is the theory underlying some of the Affordable Care Act's reforms, like accountable care organizations.
But the bottom line is this: With premium support, no one can be certain how things will work out. As we consider any premium support approach, we will need to acknowledge that one of the easiest ways to cut premiums is to shift more health care costs to older Americans.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
URL: http://www.nytimes.com/2017/01/30/upshot/a-republican-plan-for-medicare-gets-a-revival.html
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September 23, 2010 Thursday
Late Edition - Final
The Health of Reform
BYLINE: By JACOB S. HACKER and CARL DeTORRES.
Jacob S. Hacker, a professor of political science at Yale, is the co-author of ''Winner-Take-All Politics.'' Carl DeTorres is a graphic designer.
SECTION: Section A; Column 0; Editorial Desk; OP-CHART; Pg. 35
LENGTH: 103 words
The health care reform legislation, the Patient Protection and Affordable Care Act, turns six months old today. And while the main features of the act won't go into effect until 2014, the government has begun laying the foundation for the law's major pillars.
This report -- the first in a series -- grades progress in three main areas: ''Rollout'' (Are critical milestones being met?); ''Reactions'' (Are key health care and political players cooperating?); and ''Results'' (Is health care reform actually reining in insurance premiums and insuring more Americans?).
Below, some early assessments for health care reform:
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The New York Times
February 7, 2014 Friday
Late Edition - Final
Baucus Confirmed for China Post
BYLINE: By CORAL DAVENPORT
SECTION: Section A; Column 0; Foreign Desk; Pg. 6
LENGTH: 346 words
WASHINGTON -- The Senate voted 96 to 0 on Thursday to confirm Senator Max Baucus as the new ambassador to China.
Mr. Baucus, a Democrat, has represented Montana in the Senate since 1978, and as chairman of the Senate Finance Committee, he has been a major voice during many of the major policy debates of the past decade. He also was an architect of President Obama's signature legislative achievement, the Affordable Care Act.
His departure from the Senate will have a domino effect among the Senate's Democratic leaders. Senator Ron Wyden, Democrat of Oregon, who is now chairman of the Senate Energy Committee, will become leader of the powerful Finance Committee; Senator Mary L. Landrieu, Democrat of Louisiana, is expected to replace Mr. Wyden on the energy panel. Gov. Steve Bullock of Montana, a Democrat, is expected to name a replacement for Mr. Baucus.
In his farewell address on the Senate floor on Thursday, Mr. Baucus described what he called the defining period of his life -- the year he took off from college to travel to India, Japan and China.
''Before I departed, I had never thought about a life of public service, but that trip opened my eyes, it charted my course,'' he said. ''I realized how people across the globe were interconnected, and I saw the indispensable role America plays as a leader on the world stage.
''The world is getting smaller,'' he added. ''Our natural resources are diminishing. We have to find a way to work together better.''
Mr. Baucus said he was most proud of two pieces of legislation he worked on: the Affordable Care Act and a 2010 law that used the Montana National Guard's post-traumatic stress disorder screening as a model to expand such programs nationwide.
''It's been almost four years since President Obama signed the Affordable Care Act into law,'' Mr. Baucus said. ''In that time, the law has done more than any in the past half-century to expand access to health coverage.''
''It has been a challenge I am proud to have taken on,'' he added.
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/2014/02/07/us/politics/senate-confirms-one-of-its-own-as-ambassador-to-china.html
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The New York Times Blogs
(First Draft)
March 4, 2015 Wednesday
Today in Politics
BYLINE: THE NEW YORK TIMES
SECTION: US; politics
LENGTH: 1513 words
HIGHLIGHT: The fight over the Affordable Care Act returns to the Supreme Court on Wednesday as the justices hear arguments in a conservative challenge that could determine the future of the insurance program.
Supreme Court Gets Second Shot at Health Law
Good Wednesday morning from Washington, where questions about Hillary Rodham Clinton's private emails continue to percolate, Iran's nuclear aspirations have re-emerged as the topic of the hour, and even though it is March, more snow is on the way. President Obama is preparing for a trip to Selma, Ala., this weekend, but he might have health care on his mind. That's because, once again, the Affordable Care Act is having its day in court.
The fight over the Affordable Care Act returns to the Supreme Court on Wednesday as the justices hear arguments in a conservative challenge that could determine the future of the insurance program that now covers millions of people.
An hour of argument is scheduled and much of the attention will be focused on questioning by Chief Justice John G. Roberts Jr., who helped preserve the health law in an earlier case, as well as Justice Anthony M. Kennedy. Those men are considered the two votes crucial to deciding the outcome of the case, King v. Burwell.
Opponents of the law charge that Congress never meant to allow the government to grant tax subsidies to consumers who buy their health insurance through federal exchanges that were set up where states refused to participate. The White House and Democratic defenders of the law say that that is a distortion, and that Congress clearly meant the subsidies to be available nationwide.
No decision is expected until late June. The case represents the second big draw on Capitol Hill in two days, after the address by Prime Minister Benjamin Netanyahu of Israel on Tuesday. Spectators are expected to line up for a chance to witness the argument, and admission has been tough to gain because of the strong demand.
- Carl Hulse
Stay tuned throughout the day @NYTpolitics for First Draft updates
Netanyahu Speech Shifts Congressional Focus to Iran
The big foreign policy push in Congress in the coming weeks was supposed to be the crafting of an authorization for the use of military force against the Islamic State. But Prime Minister Benjamin Netanyahu's appearance on Capitol Hill has shifted the immediate focus to Iran.
After the prime minister's address, Senator Mitch McConnell of Kentucky, the majority leader, said he would bring up a bipartisan measure next week that would require Congress to be given 60 days to review a nuclear deal with Iran before any sanctions could be lifted. It would also require that all elements of the agreement be disclosed to Congress.
Senator Bob Corker, the Tennessee Republican, chairman of the Foreign Relations Committee and a chief author of the bill, said he intended to hold a hearing next Tuesday on the legislation. The bill already has six Democratic sponsors, conceivably providing enough votes to overcome a filibuster if other Democrats sought to stymie the measure.
With so much attention focused on Iran, it is doubtful that Congress can make much quick progress on the use of force measure, which lawmakers were struggling with even before Iran took center stage.
- Carl Hulse
In Public Appearance, Clinton Ignores Email Controversy
One of the final songs of the night at the Emily's List 30th anniversary gala at the Washington Hilton was Taylor Swift's "Shake It Off." And that's precisely what Hillary Rodham Clinton tried to do in her speech, which came more than three hours into the event.
Mrs. Clinton didn't address the barrage of news stories about her practice of exclusively using personal email while she was secretary of state. Questions about foreign donations to her family's foundation or stalled records requests to the State Department were left unanswered.
Instead, she made jokes about the Internet craze over "the dress," road-tested some new themes and messages about the economy, and made an overt reference to electing a female president.
Speaking to a crowd of more than a thousand women, she asked, "Don't you someday want to see a woman president?"
But Mrs. Clinton never mentioned her own plans.
She did give a nod to Senator Elizabeth Warren of Massachusetts, the Democrat who has caused her the most agita despite not running. And in a line that seemed aimed at Scott Walker, the Republican governor of Wisconsin who has boasted of his union-busting record as a credential for higher office, Mrs. Clinton said, "the American middle class was built, in part, by the right for people to organize and bargain."
That was one of the rare new lines for Mrs. Clinton, who primarily stuck to themes she first deployed during the 2014 midterm elections while campaigning for Democrats.
Questions remained on Tuesday about why Mrs. Clinton declined to set up a government email account, and about the extent to which her practice of using only a private email hindered investigators and outside groups from gaining access to those documents.
But by not addressing them, and with her allies working to undercut the original New York Times article on the emails, she is signaling that she will employ a "Rose Garden" strategy as much as possible. Although she is not holding office, she is behaving like the incumbent.
- Nick Corasaniti and Maggie Haberman
Obama and Bush to Have Rare Meeting in Selma
It is no surprise that the political parties in Washington fractured once again this week over domestic issues like immigration and foreign policy issues like Iran. But bipartisanship will be alive this weekend in Selma, Ala.
President Obama and former President George W. Bush will meet up in the small Alabama town on Saturday to commemorate the 50th anniversary of the Bloody Sunday march that became a pivotal moment in the civil rights movement after state troopers beat protesters with billy clubs.
It will be a rare joint appearance for the two presidents, who have appeared together only a handful of times since Mr. Obama succeeded Mr. Bush in January 2009. The two spoke at an event in Austin, Tex., last year marking the 50th anniversary of the Civil Rights Act, but they were not there at the same time. They saw each other a couple of times in 2013, when they both happened to be traveling in Africa and when Mr. Bush's presidential library opened.
Joining them in Selma will be their wives, Michelle Obama and Laura Bush, and the president's daughters, Malia and Sasha, as well as a delegation of dozens of members of Congress from both parties. They will gather at the Edmund Pettus Bridge, where protesters trying to march to Montgomery for voting rights were attacked by the police, an episode featured in the recent movie "Selma."
"President and Mrs. Bush believe it's important to honor such a seminal date in the history of human dignity and human rights," Freddy Ford, a spokesman for the former president, said on Tuesday. "They are pleased to have been invited and are looking forward to attending."
Mr. Obama hosted civil rights leaders at the White House last week, including a woman who had been at the Selma protest.
"When I take Malia and Sasha down with Michelle next week, down to Selma, part of what I'm hoping to do is remind them of their own obligations," the president said. "Because there are going to be marches for them to march and struggles for them to fight. And if we've done our job, then that next generation is going to be picking up the torch as well."
- Peter Baker
What We're Watching Today
President Obama will be staying put in the White House for meetings.
Senate Democrats have scheduled a 2 p.m. news conference where they will underline their support of the Affordable Care Act, just hours after the Supreme Court hears arguments in a challenge to the law.
The Senate Foreign Relations Committee is holding a hearing on Russian aggression in Eastern Europe.
Jason Furman, the chairman of the Council of Economic Advisers, delivers "The Economic Report of the President" at 2:30 p.m.
Our Favorites From Today's Times
Hillary Rodham Clinton's use of private email thwarted records requests over the 2012 attack in Benghazi, Libya.
Prime Minister Benjamin Netanyahu of Israel's address to Congress had the feel of a State of the Union.
The White House has decided not to make a contingency plan in the event that the Supreme Court guts the Affordable Care Act, in hopes that it will dissuade the court from doing so.
After months of posturing, the House of Representatives approved funding for the Department of Homeland Security with no strings attached.
With frequent talk-show appearances and cameos, Mayor Bill de Blasio of New York is becoming a fixture on television.
What We're Reading Elsewhere
Senator Marco Rubio of Florida shared a steak dinner with the Republican casino magnate Sheldon Adelson in Washington this week, Fox reports.
Reason wonders if Senator Rand Paul of Kentucky will ever be able to overcome his Israel problem.
Jon Stewart poked fun at Republicans on "The Daily Show" for fawning over Prime Minister Benjamin Netanyahu of Israel.
The Capital Weather Gang at The Washington Post are forecasting up to six inches of snow in the city Wednesday night.
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November 20, 2014 Thursday
Late Edition - Final
Obama's Plan Could Shield Four Million
BYLINE: By MICHAEL D. SHEAR and ROBERT PEAR; Julia Preston contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1147 words
WASHINGTON -- Up to four million undocumented immigrants who have lived in the United States for at least five years can apply for a program that protects them from deportation and allows those with no criminal record to work legally in the country, President Obama is to announce on Thursday, according to people briefed on his plans.
An additional one million people will get protection from deportation through other parts of the president's plan to overhaul the nation's immigration enforcement system, including the expansion of an existing program for ''Dreamers,'' young immigrants who came to the United States as children. There will no longer be a limit on the age of the people who qualify.
But farm workers will not receive specific protection from deportation, nor will the Dreamers' parents. And none of the five million immigrants over all who will be given new legal protections will get government subsidies for health care under the Affordable Care Act.
These new details about the broad reach of Mr. Obama's planned executive action on immigration emerged as he prepared to speak to the nation in a prime-time address on Thursday night. On Friday, the president is to travel to Las Vegas to rally public support for his plan in a state where Hispanics are a growing and politically powerful constituency.
Republicans on Capitol Hill sharply rebuked the president for his executive actions even before the speech on Thursday, accusing him of vastly exceeding the authority of his office. Senator Ted Cruz of Texas, in an opinion article Tuesday on the Politico website, assailed the president for embracing ''the tactics of a monarch.''
At the same time, immigration advocates rallied behind Mr. Obama's actions, describing them as a much-delayed victory for millions of people.
Administration officials have said the president's actions were designed to be ''legally unassailable,'' which activists said led the White House to make some tough choices.
Farm workers, for example, will not be singled out for protections because of concerns that it was difficult to justify legally treating them differently from undocumented workers in other jobs, like hotel clerks, day laborers and construction workers.
The White House decision to deny health benefits also underscores how far the president's expected actions will fall short of providing the kind of full membership in American society that activists have spent decades fighting for. The immigrants covered by Mr. Obama's actions are also unlikely to receive public benefits like food stamps, Medicaid coverage or other need-based federal programs offered to citizens and some legal residents.
The health care restriction may be the most immediate concern for many immigrants and for activists who have urged Mr. Obama to act to prevent deportations. Advocates for immigrant rights were infuriated in 2012 when the White House ruled that Dreamers would not get subsidized insurance coverage.
But the restriction reflects the political sensitivities involved when two of the most contentious issues in Washington, health care and immigration, collide. It also suggests that the White House has decided not to risk angering conservative lawmakers who have long opposed providing government health care to illegal immigrants and who fought to deny immigrants coverage under the Affordable Care Act.
Some advocates said this week that they saw a paradox in the president's policy. On one hand, they said, Mr. Obama plans to provide relief to millions of undocumented immigrants so that they can come out of the shadows and be better integrated into American society. On the other hand, they said, the administration is shutting them out of the health care system that would help them become productive members of society.
''We would all benefit if more people had access to health care services,'' said Angel Padilla, a health policy analyst at the National Immigration Law Center, an advocacy group for low-income immigrants.
Stephen W. Yale-Loehr, who teaches immigration law at Cornell, said he believed the president had the legal authority to decide whether the immigrants included in his executive actions qualified for health benefits.
''Just as the president has broad discretion to decide whether to allow undocumented individuals to get a temporary reprieve from deportation,'' Mr. Yale-Loehr said, ''he also has broad authority to decide whether to grant them work authorization and health benefits.''
''In this case, it appears he is willing to grant the former,'' he added, ''but not the latter.''
Senator Jeff Sessions, the Alabama Republican who has vehemently opposed giving benefits to undocumented immigrants, disagreed with that assessment.
''It is plain that President Obama has no authority to grant lawful status to those declared unlawful by the duly passed laws of the United States,'' he said. ''Nor does the president have any authority to declare such individuals eligible to receive health benefits that have been restricted to lawful residents.''
The White House decision on health benefits may be intended to undercut one line of attack by Mr. Sessions and other Republicans. In recent days, as it became clear that Mr. Obama was preparing to announce an executive order, conservative commentators and radio hosts suggested that the president wanted to give health coverage to millions of immigrants who would be given legal status.
The question of whether illegal immigrants should have access to health care benefits has long been a central part of the immigration debate. Legislation passed in the Senate in 2013 would also have denied undocumented immigrants access to federal health benefits, including the Affordable Care Act, for as long as 13 years. But in that legislation, immigrants could eventually qualify for full legal status and for federal benefits.
Sylvia Mathews Burwell, the secretary of health and human services, was asked about health care coverage in a webcast with Latina bloggers last week.
She confirmed to the bloggers that immigrants who were covered by Mr. Obama's 2012 executive actions could not receive subsidies from the HealthCare.gov marketplace. She called that decision ''more than a health care issue'' and said it had to be resolved in the context of immigration laws.
''I think everyone probably knows that this administration feels incredibly strongly about the fact that we need to fix that,'' Ms. Burwell said. ''We need to reform the system and make the changes that we need. It will lead to benefits in everything from health care to economics.''
However, she said that federal aid, including health care benefits, could be available to children who are United States citizens but living with parents who are illegal immigrants. Such so-called mixed families ''should not be scared,'' she said, because they may be eligible for coverage and financial assistance.
URL: http://www.nytimes.com/2014/11/20/us/politics/obamacare-unlikely-for-undocumented-immigrants.html
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The New York Times
January 11, 2017 Wednesday 00:00 EST
Some Republicans Try to Head Off a Health Care Calamity;
Editorial
BYLINE: THE EDITORIAL BOARD
SECTION: OPINION
LENGTH: 605 words
HIGHLIGHT: A few more sensible members of the party are now trying to slow down this runaway train.
President-elect Donald Trump and other Republican leaders may be determined to repeal the Affordable Care Act immediately, but a few more sensible members of the party are now trying to slow down this runaway train. They recognize the danger in destroying a program that directly benefits 22 million Americans - and indirectly millions more by controlling costs - without a plan to replace it.
That perhaps obvious insight has yet to penetrate Mr. Trump's reality distortion field. He said on Tuesday that Congress should vote to repeal the law as early as next week and replace it with new legislation "very shortly thereafter." His statements once again demonstrated cluelessness or indifference to how laws are made, especially in a field as complicated as health care. Most experts think that it could well take years for lawmakers to replace a law that requires insurers to sell affordable policies to people with pre-existing medical conditions, provides subsidies to help people buy insurance and encourages doctors and hospitals to reduce unnecessary and expensive medical procedures.
The House speaker, Paul Ryan, claimed on Tuesday that Republicans would try to repeal and replace the law "concurrently." He offered few details, but his statement suggests Congress won't repeal the A.C.A. for several months at least. On Monday, five Republican senators - Bill Cassidy of Louisiana, Susan Collins of Maine, Bob Corker of Tennessee, Lisa Murkowski of Alaska and Rob Portman of Ohio - faced up to that reality. They proposed slowing down a budgetary process designed by congressional leaders to effectively kill the most important parts of Obamacare by defunding them.
Two Republican governors, John Kasich of Ohio and Rick Snyder of Michigan, have said that Congress ought to preserve parts of the law, like its expansion of Medicaid, which has improved care for the poor and reduced the heavy burden of charity care at hospitals. About 665,000 people in Ohio and 614,000 in Michigan gained coverage under Medicaid expansion as of December 2015, according to the Kaiser Family Foundation.
The fact is, Obamacare is working, and it is reaching more Americans. As of Dec. 24, about 11.5 million people had signed up for health insurance for 2017 on federal and state health exchanges, 300,000 more than a year earlier. And the law made it possible for 10.7 million people to sign up for Medicaid who did not previously qualify.
Voting for repeal without a decent alternative would be inhumane. It could also be politically disastrous. About 47 percent of Americans don't want Congress to scrap the law and 28 percent say lawmakers should come up with a replacement first, according to Kaiser.
Repeal's fiscal consequences also pose a significant problem for Republican deficit hawks like Senator Rand Paul of Kentucky. The budget resolution that is the vehicle for repeal would add more than $2 trillion to the federal debt in the next 10 years, according to the Office of Management and Budget. That's partly because the law has reduced the deficit by bringing in more revenue than it spends.
If Mr. Trump, his aides and other party leaders have ideas for preserving health coverage, improving medical care and reducing costs, they ought to present them to the public before they start dismantling Obamacare. The truth is, they have nothing more to offer than campaign slogans.
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Republicans Are Courting Disaster on Health Care
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March 1, 2017 Wednesday
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Some in G.O.P. See Lack of Leadership by Trump
BYLINE: By JENNIFER STEINHAUER and EMMARIE HUETTEMAN
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 1022 words
WASHINGTON -- Congressional Republicans, racked by divisions over health care, taxes and spending, are increasingly desperate for leadership from the White House to unite the party and point the way toward consensus.
But presidential leadership does not appear to be forthcoming, leaving the party largely paralyzed at a moment it had thought would be full of legislative activity.
''The White House is huge,'' said Senator John Thune, Republican of South Dakota. ''The president is the only person who can sign a bill into law, so he's the guy that ultimately holds the whip hand when it comes to this getting done.''
As congressional leaders struggle to clear the first major legislative hurdle of the Trump era -- a bill to repeal and replace the Affordable Care Act -- their talks with the White House, though not infrequent, have failed to advance any coherent, cohesive policy prescription. Repealing the health care law is the Republicans' first step toward enacting their broader agenda.
So far, President Trump, seeking to project an image of a man of action, has preferred attention-grabbing executive actions over closed-door engagement with Congress.
In the absence of presidential leadership, the most fiscally conservative House Republicans have stepped forward to demand that the health care law be whittled to near nothingness. More moderate senators are insisting on a replacement plan with many of the current law's popular components.
Both sides are pressing hard to sway lawmakers working on draft legislation that would roll back the Affordable Care Act's expansion of Medicaid, replace the subsidies offered in the insurance marketplaces with tax credits to buy coverage, and eliminate tax penalties for people who do not have health insurance.
After weeks of loud protests across the country from voters who are fearful of losing their health care, Republican governors complicated matters further this week by joining Democrats in a call for a replacement plan that would ensure coverage for the 20 million Americans who gained insurance under the Affordable Care Act.
''I'd like to hear a renewed commitment to repealing the law,'' said Senator Mike Lee, Republican of Utah -- another sign of just how far the party is from unity.
Democrats, who have been dismissed as obstructionists by Republicans determined to repeal and replace the law without them, are sitting by quietly waiting for those efforts to fail. At that point, Democrats believe, Republicans will have to reach across the aisle and repair the law.
''We've maintained all along there is room to negotiate,'' said Senator Brian Schatz, Democrat of Hawaii. ''But only if they abandon their attempt to repeal the law.''
While he has seen no moves toward cooperation yet, ''they are in a world of hurt,'' Mr. Schatz said of Republicans, ''because none of their plans add up, and their members are starting to figure this out and the public is starting to figure this out, and they don't have Obama as a foil anymore. I think they need to fail first.''
Senator Claire McCaskill, Democrat of Missouri, who has long offered to help fix the law, said she had heard from only one Republican colleague, Senator Bob Corker of Tennessee, since the end of last year. ''I don't think Republicans have decided what they're waiting for,'' she said. ''The White House or Godot.''
Many Republicans seem to be resigned to seeking consensus on health care legislation, as well as on a budget and tax reform, without comprehensive White House guidance.
Representative Michael McCaul, Republican of Texas and the chairman of the House Homeland Security Committee, said he was relying less on a signal from Mr. Trump than on behind-the-scenes discussions between lawmakers and the administration to ''get the details filled in.''
Those details include how Mr. Trump plans to fund his call for a 10 percent increase in military spending, Mr. McCaul said. ''From a budget standpoint, these numbers are difficult to crunch,'' he said. ''We as Republicans want a stronger national defense. That money's got to come from someplace. That's where the hard decisions have to be made.''
Mr. Trump's aversion to making big changes to two of the costliest government programs, Medicare and Social Security -- something Republicans generally crave -- is not helping matters. ''That makes it even more difficult,'' Mr. McCaul said.
The president's budget outline, unveiled this week, has something for almost every Republican to hate, from the lack of so-called entitlement reform to large proposed cuts at the State Department.
''Speaking for myself,'' said Senator Mitch McConnell of Kentucky, the Republican leader, ''I think the diplomatic portion of the federal budget is very important, and you get results a lot cheaper, frequently, than you do on the defense side. So, speaking for myself, I'm not in favor'' of huge reductions at the State Department.
Senator Lindsey Graham, Republican of South Carolina, called those cuts ''dead in the water'' for him.
Many of Mr. Trump's direct contributions to the legislative process have happened through the news media, as he has signaled his priorities in interviews that have sometimes left congressional Republicans scrambling to decipher his intentions.
Representative Eric Swalwell, Democrat of California, said some of his Republican colleagues were frustrated by their inability to move forward. ''They're reading about what he wants to do at the same time I am in the paper,'' he said.
Six weeks after Mr. Trump said Republicans would provide a replacement plan for the Affordable Care Act that offered ''insurance for everybody,'' Speaker Paul D. Ryan of Wisconsin is fighting to reconcile his party's competing priorities while also contending with the occasional messaging complication from the White House.
''This is a plan that we are all working on together: the House, the Senate, the White House,'' Mr. Ryan said Tuesday. ''We're all working on this together with the administration.''
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September 23, 2015 Wednesday
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Catholic Insiders Help Obama Build Support
BYLINE: By MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; FRANCIS IN AMERICA; Pg. 16
LENGTH: 1335 words
WASHINGTON -- When President Obama's decision to require religious organizations to provide insurance with free birth control encountered the fierce resistance of the nation's Roman Catholic bishops, the president's top aides -- including Vice President Joseph R. Biden Jr. and Kathleen Sebelius, the secretary of health and human services -- set out to find a compromise.
Weeks of tense discussion failed to win support from the church's most powerful officials, including Cardinal Timothy M. Dolan of New York and others. But the president's lieutenants won over Sister Carol Keehan of the Catholic Health Association, and other liberal members of the church, who had long been allies on the president's health care law. Mr. Obama's compromise went into effect, but is being challenged in court.
For the Obama White House, obtaining Catholic support on important elements of its agenda has often involved going around the church hierarchy. And to lead that effort it has often turned to Catholic members of the president's senior staff, including Mr. Biden and Ms. Sebelius.
''What I brought with me was an experience in my elected life where I had periodic battles with bishops and lots of support, overtly, covertly, from nuns,'' said Ms. Sebelius, the former governor of Kansas, who left the administration in 2014. ''I don't see the Catholic Church necessarily as one voice.''
Mr. Obama's initial decision that religious institutions would have to pay the cost of birth control for their employees shocked even his Catholic allies. Sister Keehan, who eventually supported Mr. Obama's compromise, said the fact that Mr. Biden and Ms. Sebelius are Catholics with longstanding church relationships was critical in the negotiations.
''They had such credibility and such familiarity with various Catholic groups,'' Sister Keehan said. ''What could have become colossal misperceptions of each other's positions were quickly averted.''
When Mr. Obama was fighting to pass the Affordable Care Act early in his first term, it often fell to Mr. Biden and Ms. Sebelius to rally support among nuns and Catholic nurses, even as bishops across the country opposed the legislation.
Other prominent Catholics in the Obama administration like Denis R. McDonough, the White House chief of staff, and Tom Vilsack, the secretary of agriculture, have also developed strong bonds with the nuns and Catholic relief agencies on issues like immigration. Those connections have helped the administration to compensate, in part, for what has often been a contentious relationship with church elders.
Catholic bishops opposed the Affordable Care Act, rejected the compromise on contraception, and as Mr. Obama's position on same-sex marriage evolved, the gulf between him and the bishops widened.
''There are a lot of social justice Catholics who were excited by his election,'' said E.J. Dionne, a liberal columnist and well-known Catholic who moderated a panel discussion on poverty with Mr. Obama this year. But he added that ''more conservative Catholics were skeptical of him from the beginning.''
The result, Mr. Dionne said, has been a ''deeply complicated'' relationship between Mr. Obama's White House and the church.
Past presidents have confronted the same challenge. John F. Kennedy, who was Catholic, once remarked during his campaign in 1960 that the bishops would likely be for Richard M. Nixon and the nuns would be for him.
Arthur C. Brooks, president of the conservative American Enterprise Institute, and a Catholic, said Mr. Obama has sought the most sympathetic audience he could find.
''They are looking for allies where they can find allies,'' said Mr. Brooks, who also participated on the panel with Mr. Dionne.
Those allies are easier to find when the problems do not involve issues like abortion or same-sex marriage. Hours after the Haiti earthquake struck in 2010, for example, the president of Catholic Relief Services called Mr. McDonough, then a national security aide to Mr. Obama, to help coordinate safe passage through the chaos on the devastated island. The food was delivered.
Mr. McDonough is among the most quietly religious Catholics on the staff, according to friends and co-workers. A native of Stillwater, Minn., Mr. McDonough was one of 11 children; one of his brothers used to be a priest, and another one still is. Colleagues say he can sometimes be seen early in the morning in the White House's basement cafeteria, in quiet conversation with his priest.
Sister Keehan describes Mr. McDonough as ''very Catholic, in the best sense of that.''
As the most senior Catholic in the administration, Mr. Biden served as Mr. Obama's chief emissary to the church during the presidential campaigns. He filmed campaign commercials aimed at Catholic voters and used a lifetime of connections to help Mr. Obama win Catholics in 2008 and 2012.
In the West Wing, Mr. Biden, who occasionally takes out his rosary beads during meetings or when he is deep in thought, helped the president navigate the complexity of Catholic politics, finding support among liberal church members and helping to blunt opposition from conservatives.
He led the administration's delegation to Rome for the inauguration of Pope Francis in 2013 and has been a main point of contact with Cardinal Donald Wuerl, the archbishop of Washington, since the pope's visit this week was announced. Mr. Biden will host a delegation from the Holy See during Mr. Obama's meeting with the pope on Wednesday.
And despite stark disagreements on policy, the vice president remains personally close to the American bishops.
''There's knowledge, there's respect and there's authenticity instead of cynicism,'' said John Carr, the director of the Initiative on Catholic Social Thought and Public Life at Georgetown University. ''That doesn't mean there aren't profound disagreements.''
Mr. Biden rarely misses Mass on Sundays, even while traveling. In 2010, he sat somewhat unnoticed in the back of a small church in Seattle one Sunday as he and his wife made their way to the Winter Olympics in Vancouver. In foreign countries, aides usually find a priest to say Mass in the vice president's hotel suite, a service that is open to Catholic staff members, military aides and Secret Service agents who are traveling with him.
Over a breakfast of turkey sausage frittatas one morning this month, about a dozen Catholic leaders gathered at Mr. Biden's official residence at the Naval Observatory for a discussion about the pope's arrival.
There was little talk of policy, several participants said. Rather, Mr. Biden -- still in mourning over the death of his 46-year-old son Beau Biden in May -- led the group in a nearly two-hour discussion about the impact of Catholicism on his life and offered a tearful preview of the personal angst he would publicly demonstrate a day later, during an interview on the ''Late Show With Stephen Colbert.''
''He was disclosing the way he feels about his faith, and how it has meant so much at these different parts of his life,'' said Stephen Schneck, the director of the Institute for Policy Research and Catholic Studies at Catholic University.
Mr. Carr also attended the breakfast. He said Mr. Obama's administration has made a number of what he called ''unforced errors'' when dealing with issues of faith, especially involving the Catholic Church and issues of religious liberty.
Those mistakes -- such as the clash with the church over birth control -- might have been avoided, he said, if the president had listened more to Mr. Biden, Mr. McDonough and other Catholics in the White House, who he said understand the concerns of church leaders, even if they don't agree with them.
''This is at the core of who they are,'' Mr. Carr said. ''Some of the mistakes could have been avoided, and some of the advantages could have been maximized.''
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October 31, 2013 Thursday
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Healthy Debate
BYLINE: By STUART EMMRICH
SECTION: Section E; Column 0; Style Desk; HASHTAG NATION; Pg. 7
LENGTH: 311 words
Who would have guessed that 36 years after she helped introduce ''jiggle TV'' as part of the original ''Three's Company'' cast (and decades after she first touted the body-shaping benefits of the ThighMaster), Suzanne Somers would have been recruited by The Wall Street Journal to offer criticism of the Affordable Care Act? Her article, ''The Affordable Care Act Is a Socialist Ponzi Scheme,'' in which Ms. Somers cited the Canadian health care system as a cautionary tale and quoted (somewhat inaccurately, it appears) Churchill and Lenin, quickly caught the attention of the Twittersphere.
Chillian J. Yikes! @jilliancyork
I Starred In Two Mediocre Sitcoms, Let Me Explain Government To You. http://t.co/3qiyVHs0gV
The Atlantic Wire @TheAtlanticWire
Having conquered cellulite, Suzanne Somers takes on Obamacare http://t.co/vjkTx99Kjv
Casey Seiler @CaseySeiler
WSJ's blog The Experts is aptly named when it features commentary from policy specialists like Suzanne Somers: http://t.co/0575aTum9J
HELL-OL GOP @LOLGOP
''Don't trust me. Ask Suzanne Somers!''
- Winston Churchill & Vladimir Lenin
Sam Stein @samsteinhp
When you've lost Suzanne Somers.... http://t.co/k6b2IxVxXI
Dave Weigel @daveweigel
Suzanne Somers now leads in early Iowa 2016 caucus polls http://t.co/VFfugXJb1L
Brian Beutler @brianbeutler
Free idea: Repeal Obamacare, replace with individual ThighMasterâ[#x201e]¢ mandate http://t.co/GecZLrYhBZ
Drew Snyder @drewbsnyder
Now that Suzanne Somers has weighed in on Obamacare, I'm pretty curious to see how Urkel feels about a Grand Bargain
Judd Legum @JuddLegum
Suzanne Somers Obamacare Op-Ed in the WSJ already has 3 corrections http://t.co/Aq9r6tA1J4
Monica Crowley @MonicaCrowley
My smart & fearless friend @SuzanneSomers truth-telling about Obamacare in today's Wall St Journal -- > http://t.co/anAHes7Bu2 via @WSJ
Suzanne Somers @SuzanneSomers
@MonicaCrowley thanks Monica

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March 23, 2012 Friday
Late Edition - Final
House Votes to Kill a Medicare Cost Panel
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 708 words
WASHINGTON -- In a rebuff to President Obama, the Republican-controlled House passed a bill on Thursday to abolish a Medicare cost control board created by the new health care law.
The bill, approved by a vote of 223 to 181, provoked a full-throated debate on the merits of the law, the Affordable Care Act, on the second anniversary of its signing by Mr. Obama.
In dozens of speeches, Congressional supporters and opponents of the law previewed arguments that will be made next week when the Supreme Court hears a challenge to its constitutionality filed by 26 states.
The Obama administration, eager to showcase benefits of the law for consumers, said it had found that insurance rate increases affecting more than 42,000 people in nine states were unreasonable.
Kathleen Sebelius, the secretary of health and human services, reviewed the rates using authority provided by the new law. She said Thursday that insurers should rescind the increases, issue refunds to consumers or publicly explain their refusal to do so.
Insurers said the higher rates were justified by rising medical costs.
The stated purpose of the new panel, the Independent Payment Advisory Board, is to ''reduce the per capita rate of growth in Medicare spending.'' Spending cuts recommended by the 15-member board would take effect automatically unless Congress voted to block or change them.
''The Independent Payment Advisory Board encompasses all that is wrong with the Affordable Care Act,'' said Representative Michael C. Burgess, Republican of Texas. ''It is not accountable to any constituency, and it exists only to cut provider payments to fit a mathematically created target.''
The House vote generally followed party lines. Seven Democrats voted for the bill, and 10 Republicans voted against it.
A number of powerful House Democrats dislike the board because, they say, it could usurp the power of Congress to set Medicare policy.
But most Democrats voted against the bill because it also included proposals that could limit patients' ability to recover damages for injuries suffered as a result of medical malpractice.
In the Senate, Republicans said they would push for similar legislation, perhaps by offering amendments to other bills. Senate Democrats vowed to block such efforts.
Representative Allyson Y. Schwartz, Democrat of Pennsylvania, said she wanted to eliminate the board because lawmakers should ''take responsibility for Medicare.'' But Ms. Schwartz said Republicans had destroyed any hope of bipartisanship by ''linking repeal of the board to tort reform, an unrelated, divisive and polarizing issue.''
Representative Pete Stark of California, the senior Democrat on the Ways and Means Subcommittee on Health, said that he, too, opposed the board, but that it was ''far less dangerous to Medicare than the voucher plan put forth in the House Republican budget this week.''
The White House threatened to veto the House bill and defended the payment advisory board, saying it ''will help reduce the rate of Medicare cost growth responsibly while protecting beneficiaries.''
Under the law, the board cannot make recommendations to ''ration health care,'' raise revenues or increase beneficiaries' premiums, deductibles or co-payments.
Republicans said the board would inevitably try to save money by cutting Medicare payments to doctors, who would then be less willing to treat Medicare patients.
''I have been a practicing physician for over 15 years, and I don't think I have seen anything potentially more detrimental to seniors' health care than the Independent Payment Advisory Board,'' said Representative Larry Bucshon, Republican of Indiana and a heart surgeon. ''No president should have the power to create a board with this much control over health care.''
Representative Alcee L. Hastings, Democrat of Florida, said: ''I am appalled by the hypocrisy of my Republican colleagues who keep stating that federal spending needs to be kept under control. But at the first opportunity, they wind up rejecting one of the most serious tools in place to actually tackle Medicare spending and make care more affordable.''
The Congressional Budget Office estimated that repealing the board could increase Medicare spending by a total of $3 billion from 2018 through 2022.
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November 10, 2014 Monday
Late Edition - Final
A Veteran Actor's Backstage Fight for Affordable Health Care
BYLINE: By RACHEL L. SWARNS.
Email: swarns@nytimes.com Twitter: @rachelswarns
SECTION: Section A; Column 0; Metropolitan Desk; THE WORKING LIFE; Pg. 17
LENGTH: 922 words
Richard E. Waits was lying in bed hours before his audition, envisioning his metamorphosis. He closed his eyes and imagined his easy stride transformed into a jaunty strut, his smooth baritone sinking into a gravely rasp.
But his anxieties kept intruding on his meditations. In about seven weeks, the health fund for Actors' Equity, the union that represents theater performers, will drop Mr. Waits and scores of other struggling actors from its health insurance plan.
So Mr. Waits, 51, found himself staring at the ceiling on Tuesday, wondering how he would cope when his insurance ran out and how he would manage the higher costs of a new plan.
He had to get to his audition for a production of ''The Wiz,'' so he swallowed his fears and rushed out of his Harlem apartment. This will all work out, he told himself, as he headed downtown on the subway and prayed for a reprieve.
But we live in uncertain economic times, and these things do not always work out. Last month, Walmart Stores announced that it was eliminating health coverage for 30,000 part-time workers, joining Home Depot, Target and Trader Joe's, which have dropped benefits in response to the Affordable Care Act, the Obama administration's health care overhaul.
Similar changes are rippling beyond corporate America. In September, the Freelancers Union announced that it would stop providing health insurance to all 25,000 members who receive it. And this summer, the trustees of the Equity-League Health Trust Fund decided to eliminate coverage for actors who have struggled to find union work and can now obtain care through state health insurance exchanges. About 200 performers will be affected by the change, the trustees said.
The actors' health fund provides coverage to about 6,000 Actors' Equity members, who qualify for six months of health insurance after they have performed at least 12 weeks a year on union jobs. (Actors who work 20 weeks a year qualify for 12 months of coverage.)
For decades, the fund also provided insurance to longtime actors who did not meet the work requirement, once they exhausted benefits under the federal insurance law known as Cobra. Without such a program, the trustees worried, actors with pre-existing conditions, such as H.I.V. or cancer, would be left uninsured.
These actors are often older people who struggle to find union jobs, or performers with chronic illnesses. They pay high monthly premiums, but those premiums cover less than half the cost of providing their care, fund officials said.
Christopher Brockmeyer, co-chairman of the Equity-League Fund, said it could no longer sustain those costs -- which amount to about $3 million a year -- while maintaining benefits for the rest of the membership.
''We are very painfully aware of the fact that some people are going to be displaced by this modification,'' Mr. Brockmeyer said. ''These aren't easy decisions for us.''
It's not personal. It's about the rising costs of health care, the mounting pressure to cut costs, and the availability of state health care. It's our new normal: regrettable, some employers and health fund managers said, but inevitable, unavoidable, inescapable.
To Mr. Waits, it felt like betrayal. On Tuesday afternoon, he delivered a full-throated number as he auditioned for the title role of the wizard in a Midtown Manhattan studio. By evening, he looked deflated.
After 33 years in show business, Mr. Waits had come to view his insurance as a lifeline that buoyed him through the ups and downs of an acting career.
In January, it will be replaced by a plan provided by the state's health insurance exchange -- one that is more costly, has been rejected by three of Mr. Waits's doctors and does not provide coverage if he gets hired for out-of-state productions like ''The Wiz,'' which will be staged in Florida.
''I feel like I've been sold a dream,'' said Mr. Waits, who has performed in concerts staged on Broadway and has acted in Off Broadway productions.
''I'm told that the union is there to protect us, to nurture professional performers,'' he said. ''But they're not looking out for me. That's a fairy tale.''
Mr. Brockmeyer emphasized that the trustees of the health fund -- not the staff at Actors' Equity -- made the decision to cut benefits. (Union officials, who denounced previous cuts in coverage, said in a statement last week that it was ''essential'' for the plan ''to remain as viable as possible.'')
Health fund trustees also point out that actors will be allowed to keep their insurance if their new plans are too costly; if they have medical conditions that require particular specialists or prescription drugs that are unavailable under the new plans; if they travel for union jobs; or if they meet other requirements.
That is small comfort to Mr. Waits, who has trouble at times with his vision, his hips and his neck, has other chronic conditions and has struggled to stay afloat financially. His new plan will cost $46 more a month -- ''That's the telephone bill,'' he said. He has spent weeks pleading with the health fund to allow him to keep his current coverage.
By Friday, Mr. Waits had received a callback for a second audition for ''The Wiz.'' And La MaMa Experimental Theater had agreed to showcase his one-man production, ''Mama Rose.''
But there was no final word on his health insurance. For that, he was still waiting.
Rachel Swarns would like to hear about your experiences in New York's work world. Please contact her directly by filling out this brief form. She may follow up with you directly for an interview.
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September 4, 2014 Thursday
Late Edition - Final
After Slow Growth, Experts Say, Health Spending Is Expected to Climb
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 836 words
WASHINGTON -- Government experts on Wednesday predicted a rebound in national health care spending as expansions in coverage and improvements in the economy take hold after four years of exceptionally slow growth in the nation's medical bills.
The combined effects of the Affordable Care Act, faster economic growth and the aging of the population will fuel the growth of health spending this year and in the coming decade, according to a report by a team of nonpartisan economists and actuaries at the Centers for Medicare and Medicaid Services.
''The period in which health care has accounted for a stable share of economic output is projected to end in 2014, primarily because of the coverage expansions of the Affordable Care Act,'' said the report, by Andrea M. Sisko and colleagues at the federal health care agency.
Still, they said, even as millions of people gain coverage, the average annual rate of increase in health spending through 2023 will be somewhat lower than it was in the two decades before the recession that began in late 2007.
The expected increases will be somewhat dampened, the report says, by slower growth in Medicare payment rates required by the new health care law and by a trend toward higher co-payments and deductibles, which tend to discourage people from using services provided by private insurance. In addition, it said, a new excise tax on high-cost employer-sponsored health plans, starting in 2018, ''is expected to slightly constrain premium growth.''
In their annual projections of health spending, the experts predicted that the total would climb 5.6 percent this year and then an average of 6 percent a year until 2023, when health care will account for 19.3 of the nation's total output -- two percentage points more than last year.
By 2023, the report said, national health spending will total $5.2 trillion, up from $2.9 trillion in 2013. The federal share of all health spending will increase, and the share paid by state and local governments will remain constant, while the shares paid by households and private businesses will decline a bit, said the report, published online Wednesday in the journal Health Affairs.
The report estimates that nine million uninsured Americans are gaining coverage this year through Medicaid and private insurance. That is somewhat lower than estimates by administration officials and the Congressional Budget Office, which said in April that the number of uninsured would decline this year by 12 million.
From 2013 to 2015, the new report says, federal spending on Medicaid will increase 27 percent to $323 billion, from $254 billion. In those years, it said, Medicaid spending by state and local governments will rise 12 percent to $218 billion, from $195 billion.
The federal government will initially pay all the costs resulting from the expansion of Medicaid eligibility in states that choose to cover certain childless adults with low incomes. States will have to pay some of the cost for new beneficiaries who could have qualified for Medicaid under old eligibility rules.
''Additionally,'' the report said, ''some large employers of low-wage employees will elect to no longer offer health insurance to their employees by 2016. As a result, a portion of these affected employees will qualify for, and enroll in, Medicaid.''
The experts estimated that spending on prescription drugs would increase at a rapid clip, rising 6.8 percent this year and 6.4 percent next year.
''This is primarily a result of increases in the use of prescription drugs by the newly insured and by those who have switched to more generous insurance plans'' because of subsidies offered under the Affordable Care Act, the report said. ''Early analysis indicates that compared to other forms of private health insurance, marketplace plans are experiencing greater use of drugs in several therapy classes, including higher use of specialty drugs. In addition, expensive new hepatitis C treatments are expected to contribute to an acceleration of drug spending growth in 2014.''
While many factors will tend to increase the use of prescription drugs, the experts estimate that drugs will account for the same share of total health spending, 9.4 percent, in 2023 as in 2013.
Ms. Sisko and her colleagues said that the growth of health spending in recent years had been constrained not just by the recession, but also by an unusually slow economic recovery.
Obama administration officials have said that innovations in the delivery of health care, inspired by the Affordable Care Act, are reining in the growth of health spending. The authors of the report said they were hopeful but wanted to see the results of demonstration projects.
''It's still too soon to say what the ultimate impact of the delivery reforms will be,'' Ms. Sisko said.
The experts forecast substantial growth in Medicare enrollment and spending, but said the growth in spending would be moderated by cutbacks in payments to private Medicare Advantage plans, which cover about 30 percent of beneficiaries.
URL: http://www.nytimes.com/2014/09/04/us/health-care-spending-to-rise-federal-experts-predict.html
LOAD-DATE: September 4, 2014
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GRAPHIC: CHARTS: Why Expenditures Are Going Up: Expanded insurance coverage under the health care law, economic growth and an aging population are expected to contribute to faster growth in national health spending over the next decade, according to a panel of experts at the Centers for Medicare and Medicaid Services. (Sources: Health Affairs
Centers for Medicare and Medicaid Services)
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December 7, 2013 Saturday
Late Edition - Final
Health Care Law Providing Relief and Frustration
BYLINE: By JOHN SCHWARTZ and KATIE THOMAS
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1283 words
CHARLOTTE, N.C. -- Mike Horrigan is a lifelong Democrat with heart problems who supports President Obama's health care law because he expects it will help many people obtain better insurance, including himself.
But under the new law, the Affordable Care Act, Mr. Horrigan's coverage by a state high-risk insurance program was eliminated, then replaced by a more expensive plan. His wife's individual plan was canceled for being substandard, then suddenly renewed -- also at a higher price.
So while Mr. Horrigan, 59, believes the law will improve health care in the long run, its short-term effect has been chaotic and trying for him and his wife, Kay. ''It's more stressful than it needed to be,'' he said.
For a measure of the tumult that has accompanied the arrival of the federal health care overhaul, there may be no better place to look than in the politically mixed state of North Carolina, where both the anxiety and the promise of revamping the health insurance system has left hundreds of thousands of people struggling to sort out their options.
Many will end up with better coverage than they had, and may get help paying for it. Others will see their costs rise and are wondering if the change is worth it. And some, like the Horrigans, may find themselves falling into both camps.
The agitation has been building for months. This fall, insurers notified about 260,000 North Carolinians that their individual health plans no longer complied with the law's more stringent requirements, and many learned that the plans they were being offered as replacements would cost hundreds of dollars more per month. Then, after Mr. Obama said on Nov. 14 that insurers would be allowed to renew their plans for one year, Blue Cross and Blue Shield of North Carolina announced that 230,000 of its customers in the state could keep their own plans -- but at prices that rose 16 percent to 24 percent.
Kathleen LaFleur, a broker who works with people who have individual plans at Employee Benefit Advisors, an insurance agency here, said many of the callers to her office had two things in common: confusion and anger. ''They are confused before they call,'' she said. ''After they call, they're not confused anymore. They're angry.''
Adding to the confusion is the fact that many consumers have been unable to fully evaluate their options because the federal health care website, which serves residents of North Carolina and 35 other states, did not work very well until recently. Those who qualify for subsidies must sign up through the federal marketplace. Consumers have until Dec. 23 to sign up for coverage beginning in January.
''It has obviously been extremely frustrating for individual policyholders who have received cancellation notices at a time when there's such a short window for them to decide what their coverage options will be,'' said Wayne Goodwin, North Carolina's insurance commissioner, an elected Democrat.
Still, for some, the new law is working well. Rachel Bryant, a small-business owner who lives just outside Winston-Salem, felt unlucky when she received a notice from Blue Cross saying that her plan was being canceled and that the replacement would raise her monthly bill to $675 from $408.
But when Ms. Bryant, a single mother of two young children who earns about $30,000 through her legal services business, finally succeeded after many tries to log onto the online marketplace, HealthCare.gov, she learned she was eligible for subsidies that would bring down her premiums to just $150 a month.
''I'm extremely happy,'' said Ms. Bryant, 36. ''I'm not going to go bankrupt because of medical bills. I'm looking forward to it, and I'll put up with the frustration and the bother.''
About half of those buying individual insurance in the existing market will be eligible for a subsidy, according to a national study by the Kaiser Family Foundation. That does not include an additional one million people who buy individual insurance now but, under the provisions of the health law, will be eligible for Medicaid beginning in 2014, according to the study.
For others, like the Horrigans, the transition is proving uncomfortable.
Ms. Horrigan, 61, is a former psychiatric social worker; Mr. Horrigan is a former corporate human resources expert who started a consulting business in Charlotte after atrial fibrillation required two heart surgeries. Because of his heart problem, he was denied insurance and found coverage through North Carolina's high-risk insurance pool.
So they understood, Mr. Horrigan said, why the Affordable Care Act was necessary. The new law was designed to fix flaws in the old market in which people with existing medical conditions, like Mr. Horrigan, could find themselves uninsurable and without limits on out-of-pocket costs -- people for whom serious illness often meant financial ruin. Under the new law, such people cannot be turned away or be charged more by insurers, and subsidies are available to those whose incomes fall below a certain level.
''I was a poster child for why folks should have this opportunity,'' Mr. Horrigan said.
Then realities set in. Because of the law, the state eliminated the high-risk pool that provided his coverage, for which he paid about $400 a month. Then Ms. Horrigan learned that her insurer, Blue Cross, was discontinuing her plan -- which was deemed substandard under the new law -- and replacing it with one that would cost $620 a month, up from $325, with a higher deductible as well.
Now, after Mr. Obama's reversal, Blue Cross says it will extend her policy, though at a higher cost: She will get a one-year rate of $402, an increase of 23.6 percent, she said. After all the confusion, she will renew -- and her husband has selected a midlevel plan through Blue Cross that will cost about $670 per month.
Calling the increases ''unreasonable,'' Ms. Horrigan acknowledged that they may be necessary to make the new system work.
''I appreciate the irony of complaining about my premiums being increased when it protects somebody like my husband,'' she said. ''I reluctantly say we will probably be better off even though it hits us hard in the pocket.''
Prices are rising for several reasons, including the law's higher standards for coverage, and fees and taxes associated with it, said Barbara Morales Burke, vice president for health policy at Blue Cross in North Carolina. But she said the sticker shock some are feeling also has another cause: For years, insurers could charge people different prices based on factors like their health or gender. Now that the law prohibits such practices, some who benefited from the old system will be asked to pay more, while those who had been at a disadvantage will see some relief.
''This is a disruption to the marketplace,'' she said, and estimated that about a third of Blue Cross's individual insurance customers would see a significant increase in their rates.
Dr. David Naftolowitz, a psychiatrist in Durham, is among them. He was offered a replacement plan that would raise his monthly cost to $410 from $199. His deductible would rise to $5,500 from $5,000. He plans to extend his existing policies for a year, but said the extension was ''like a teaser'' that ''takes the heat'' off the president for the moment.
''You're going to be hit a year from now,'' he said.
Ms. LaFleur, the broker, said that once her clients have been through the process and make their choices, they tend to calm down. ''They can exert some control, and that makes them feel better,'' she said.
There is one silver lining in the tumult: Suzy K. Johnson, Ms. LaFleur's boss, says she plans to expand. ''I'm growing my team,'' she said. ''This is an opportunity -- they need us more than ever.''
URL: http://www.nytimes.com/2013/12/07/us/politics/health-law-eases-some-worries-but-creates-others-in-north-carolina.html
LOAD-DATE: December 17, 2013
LANGUAGE: ENGLISH
GRAPHIC: PHOTOS: Kay and Mike Horrigan of Charlotte, N.C. He was in a high-risk insurance pool, and her policy was canceled under the law.
The Affordable Care Act has raised the Horrigans' costs.
Kathleen LaFleur, an insurance broker, said callers are initially confused, then angry. With help, she said, they calm down. (PHOTOGRAPHS BY TRAVIS DOVE FOR THE NEW YORK TIMES) (A12)
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(You're the Boss)
November 25, 2014 Tuesday
My Mission to Buy Small Business Health Insurance Begins Again
BYLINE: PAUL DOWNS
SECTION: BUSINESS; smallbusiness
LENGTH: 862 words
HIGHLIGHT: Based on past experience with the Affordable Care Act, this year’s search is likely to take about half of my working hours over a six-week span.
Every November, I return to my annual task of making a decision about health insurance. I've been offering this benefit to my employees for more than 20 years, and some aspects are predictable (cost increases) while others are different every year (my choice of plans, the consequences of dropping coverage.)
Last year, obviously, was my first look at the world of Affordable Care Act plans, and I ended up spending way too much time trying to figure out what to do. I kept at the task in part because I knew that, given my ability to share what I found with You're the Boss readers, the time I spent was likely to help other bosses, too.
If you have also decided to offer insurance to your employees, and you don't feel as though you have a good grasp of how it all works, you might want to take a look at three posts I wrote last year: one on how health plans work, one on how premiums vary with age under the A.C.A. and one on how to evaluate your out-of-pocket health care costs. Here's a quick recap of what I learned:
First, it's important to keep in mind that a health insurance plan is a set of rules, designed by an insurance company, that divides the costs of covering enrolled members into two pots: an amount collected through premiums and an amount collected directly from the members as they use services.
The A.C.A.-mandated metallic levels refer to plans that divide the total spending in different ways: In platinum plans, members commit to pay 90 percent of the total spending as premiums. For gold, it's 80 percent, silver is 70 percent and bronze is 60 percent. The rest will be collected as deductibles, co-pays, and co-insurance.
Note that these percentages do not apply to individual spending but to aggregate spending by the enrollees. If subscribers don't go to the doctor, their costs are only the premium. If they do go, they may have significant out-of-pocket expenses, particularly in silver and bronze plans. In fact, if the subscriber's premium costs are subsidized by an employer, the out-of-pocket expenses may be the largest and most important expenses for an employee to consider. (I'll be writing more about this in my next post about my own experience this year with a bronze policy.)
Second, premiums in policies sold on the federal exchange vary with the age of the subscriber. The increased cost for each year of aging varies, but on average, from age 20 to 64, it's 2.65 percent. If you add in the huge jump in premium between age 18 and 19, the average for all adult years is 3.85 percent. If you are comparing premium costs for a given plan from one year to another, you must take this into account, because everyone will be a year older next time they buy insurance.
That means that if your agent tells you that premium costs for a given plan went up X percent from the previous year, it probably means that all of the subscribers who choose to stay in that plan will actually see a premium increase of X plus 2.65 percent (2.65 percent on average - the actual jump varies depending on how old the subscriber is). If you renew last year's plan, look carefully at how the costs are presented to see if the agent has included this jump.
Finally, keep in mind that there's no way to predict what you and your employees will be charged in any encounter with the health care system. It depends on what procedure is required, who does it, where it is done, what price the insurance company negotiated with the provider, and how the policy shares the costs with the subscriber. There is no way to compare the rates that different insurance companies have negotiated for a given procedure.
This means that the only hard data point you have at the time you buy insurance is the out-of-pocket maximum for each policy. Here's the strategy I recommend: When comparing plans, add the out-of-pocket maximum to the annual premium cost and compare worst-case cost scenarios. Ask yourself how likely it is that you or your employers could come up with the whole out-of-pocket amount if it should prove necessary. Any other way of thinking about the cost is a form of gambling, with the cheapest policies placing the greatest risk on subscribers.
Given all of that, I plan to write a series of posts about my journey through this year's renewal. Here's my list of the tasks I will complete (and the issues I will write about):
Evaluate the information and plans provided by my insurance agent (and others).
Evaluate the plan I chose last year to see how my actual experience differed from what I was told to expect.
Decide which company to patronize this year and which policy or policies to offer my employees.
Explain the choices to my employees.
Based on past experience, this will probably take about half of my working hours over a six-week span (not including the time I spend writing about it). And then I will have to administer the plan through the course of the year.
Can anyone suggest a quicker or easier way to make an informed decision? Or are you just throwing up your hands and either dropping coverage for 2015 or just going with what your agent recommends?
Paul Downs founded Paul Downs Cabinetmakers in 1986. It is based outside Philadelphia.
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February 26, 2015 Thursday
Bobby Jindal on Obamacare, ISIS and the Big Gulp
BYLINE: NICK CORASANITI
SECTION: US; politics
LENGTH: 210 words
HIGHLIGHT: Gov. Bobby Jindal offered three “key points” at CPAC: Repeal “every single word” of Obamacare and Common Core, and double down on fighting the Islamic State.
Best Applause Line: "President Obama has shown himself incapable of being our commander in chief," said the governor of Louisiana.
Crickets: Not quite. But only muffled laughter and a few claps greeted this one: "They think if you live in New York City, you're not smart enough to drink the Big Gulp."
Red Meat: Repeal Obamacare! Repeal Common Core! (Repeat.)
Toughest Question: Mr. Jindal handled almost every question that came his way with a direct and seemingly prepared response. He only dodged one, which wasn't exactly a stumper. His 2016 intentions? "I'll make that decision in a couple of months," he said.
Entrance Song: A country song this reporter embarrassingly couldn't recognize.
Mood in the Room: Enervated. Some of the electricity, and some of what had been a standing-room-only crowd, left along with Gov. Scott Walker of Wisconsin, who preceded Mr. Jindal.
Mr. Jindal rarely raised his voice and focused on three "key points" - repealing the Affordable Care Act, getting rid of Common Core, and battling the Islamic State.
Many in the audience dutifully listened to his detail-laden descriptions of the problems of Obamacare and Common Core, cheering at his applause lines, but the crowd's enthusiasm never matched the response for Mr. Walker.
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June 30, 2012 Saturday
Late Edition - Final
For Obama, a Signature Issue That the Public Never Embraced Looms Large
BYLINE: By PETER BAKER
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1248 words
WASHINGTON -- On the day President Obama took the final step in turning the Affordable Care Act into law, his senior adviser, David Axelrod, predicted the public would eventually embrace his ambitious effort at health care reform.
''As the American people become familiar with what this program is and what it isn't,'' Mr. Axelrod said, ''they're going to be very, very happy with it.''
Two years later, the public is no happier with the law than it was then. Mr. Obama's signature initiative may have prevailed in the Supreme Court, but a White House that vowed a public relations blitz selling the act's virtues never fully followed through, much to the frustration of many Democrats and even some of the law's authors.
Now Mr. Obama faces the consequences as he heads toward a hotly contested election that will decide whether he has a second term and, by extension, whether the law will survive efforts to repeal it.
And while the White House and its allies sent e-mails and held conference calls promoting the overhaul soon after the Supreme Court victory on Thursday, they privately made clear their interest in moving the national conversation back to the economy, the main electoral battleground.
''Unfortunately, we never had a really effective strategy around communicating to the public the benefits and the rationale behind health care reform,'' said Ezekiel J. Emanuel, a physician and University of Pennsylvania vice provost who was a top White House adviser involved in developing the program. ''We never had a spokesperson, and the public never really understood what we were doing.''
That failure still baffles supporters like Dr. Emanuel, given the significance of health care to Mr. Obama's legacy. Some see it as a result of the president's own instinctive diffidence or the natural desire to move to the next challenge. Others note the complexity of the act itself, or criticize the president's advisers for not being more assertive.
But there was also calculation on the part of White House officials who concluded that the public was fatigued with the subject and more concerned about jobs. As they pondered plans to sell the overhaul, they found few troops to rally. Democratic lawmakers ran away from it and party donors refused to finance advertising to promote it.
''No one in history has ever been able to communicate successfully about health care, because it is a deeply personal and polarizing issue and people are therefore afraid of the unknown,'' said Dan Pfeiffer, the White House communications director. ''We need the law to be fully in effect before the known overtakes the unknown.''
Mr. Obama's team holds out hope that with the validation of the court ruling, the health care law will generate more popular support as it is phased in through 2014. And they take heart from polls showing that elements of the law, like protections for those with pre-existing conditions, rate high with the public.
Some supporters have argued that other social programs in the past were controversial at first before becoming embedded in American society. But polling suggests that is not so.
Social Security was popular from the start, supported by 73 percent of Americans in early 1937 and 78 percent the next year in Gallup polls. Medicare had the approval of 62 percent in early 1965 and 82 percent by the end of that year in Harris polls.
By contrast, just 32 percent supported the Affordable Care Act when it was approved in March 2010, according to a New York Times/CBS News poll. As of a month ago, 34 percent supported it, virtually unchanged. To be sure, about a fifth of those who oppose it say it did not go far enough, essentially frustrated liberals.
That Mr. Obama's presidency may be defined by the law would have seemed unlikely in March 2007, when as a presidential candidate he showed up for a health care forum in Las Vegas unprepared, by his own admission. When he finally developed a plan, he rejected requiring American adults to obtain health insurance and pilloried his chief opponent, Hillary Rodham Clinton, for supporting it.
As he took office, health care was on his agenda but not yet dominant. The economy was in a free-fall; health care competed with issues like climate change and immigration for Mr. Obama's political capital. One adviser said if the White House had realized the economic troubles would be as sustained as they have been, health care might never have been on the table. Others disagree, arguing that health care did not detract from efforts to promote recovery.
Either way, health care rose to the fore in part through circumstance. The House passed a climate change bill, but it took deal-making and lobbying that alienated some around Mr. Obama. The White House concluded that the Senate could not pass the climate plan with only Democrats, since some from coal states opposed it. Likewise, Mr. Obama lost Republican cooperation on immigration, leaving health care the most plausible initiative.
''It wasn't a choice so much as, of the three issues, the only one that had a chance was health care,'' said a senior administration official who asked not to be named discussing priorities.
To pass health care, Mr. Obama abandoned his campaign position on the mandate. ''The president we had to convince, because it was going back on what he promised,'' Dr. Emanuel recalled. ''But once we effectively laid out for him why this would be a better argument, he was convinced this was the right move.''
Still, some urged the president to narrow his ambitions, including Rahm Emanuel, his chief of staff and Dr. Emanuel's brother. And victory came after an ugly process: closed-door deals with the pharmaceutical industry, policy inducements to recalcitrant lawmakers, legislative legerdemain after a Massachusetts special election cost Democrats their filibuster-proof supermajority.
To win over an unenthusiastic public, officials promised an aggressive campaign. In April 2010, a month after the law was signed, the White House hired Stephanie Cutter, a prominent Democratic strategist, to handle public outreach for it. But she was given other projects as well, and by August had been reassigned as Mr. Axelrod's deputy. The White House and its allies made efforts to educate the public, hosting events and posting information online, but it was sporadic.
Critics say public discontent stems not from how the president sells the overhaul, but what he is selling.
''Democrats can point to a couple of aspects that light up some numbers for them, but when weighed against the negatives they get blown away,'' said Jonathan Collegio, communications director for American Crossroads, a group that supports Mitt Romney for president.
Groups like Crossroads swamped the president's allies with television advertising. Since the law's passage, $235 million has been spent on ads attacking it, compared with $69 million for those supporting it, according to Kantar Media's Campaign Media Analysis Group.
''I'd be a heck of a lot happier if I had $100 million too,'' said Eddie Vale, communications director for Protect Your Care, which supports the law. ''But we're playing with the hand we've been dealt.''
As for the president, he has promoted his program in fits and starts. In his State of the Union address this year, he devoted two sentences to it -- 44 words out of more than 7,000. Aides said they decided to focus on jobs.
''That is the A-No. 1 issue on people's minds,'' Mr. Pfeiffer said. ''You can't do both. You have to make choices.''
URL: http://www.nytimes.com
LOAD-DATE: June 30, 2012
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GRAPHIC: PHOTO: Just 32 percent supported the Affordable Care Act when it was approved in March 2010. The number has not changed much. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)
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December 11, 2016 Sunday
Late Edition - Final
Trump-Era Health Care
SECTION: Section SR; Column 0; Editorial Desk; LETTERS; Pg. 10
LENGTH: 1120 words
Readers discuss the challenges the G.O.P. will face with its promise to replace Obamacare.
To the Editor: Re ''A G.O.P. Plan on Health Act: Rescind Slowly'' (front page, Dec. 3):
This article is just the latest indication that health care legislation is going to be a huge problem for Republicans. As the former chief executive of John Hancock Insurance Company, which once sold health insurance, I think it is fair to say that health insurance sold on an individual basis is a difficult proposition no matter how it is done.
If it is sold like any other product, people with pre-existing or chronic conditions will be turned down or will not be able to afford it. If exceptions are made, insurance companies will struggle to make a profit. None of the ideas being trotted out for the ''replace'' portion of the ''repeal and replace'' have much effect on the basic problem. This is not to say Obamacare is great; it isn't. As one example, the penalty for not buying insurance was much too low. However, the idea of repealing before knowing exactly what will replace it is a recipe for chaos for everyone involved.
Republicans are also spending far too little time on trying to deal with the underlying problem of costs. A couple of suggestions: How about requiring hospitals to publish their prices, and allowing Medicare to negotiate drug prices (which Donald Trump backed as a candidate)?
STEPHEN BROWN
Palm Beach, Fla.
To the Editor: This is some of the nuttiest, ill-thought-out political rationalizing I have ever seen. According to this article, Republicans plan to strip out the mandate and tax penalties in Obamacare, leaving the remainder to deal with later.
President Obama's handling of the Affordable Care Act was among the most artless, bungled bits of leadership in recent history. To order significant parts of the population to buy something they didn't think they needed or could afford and then slap them with a penalty for not doing it before getting their buy-in was amateurish in the extreme. That doesn't change the fact that a mandate was essential for creating a working risk pool. Then delaying enforcement of the mandate made escalation of premiums inevitable, further strengthening the argument that the plan was flawed. But Republicans will not be able to devise a workable, affordable insurance program without a mandate. It is simple mathematics.
While Republicans play petty politics and twist themselves into pretzels just to vent their petulant resentment against Barack Obama, millions of people's lives are being toyed with, and we watch in horror a charade of governing by people without the least idea of what they are doing.
ROBERT MILLSAP
Woodland, Calif.
To the Editor: While Republicans in Congress debate ''repeal and replace'' health care for millions of us, what about their guaranteed health care? That's an entitlement program to question. Why do members of Congress have better guaranteed health care than the people whom they represent? Let's ask them how they would like the changes they are considering proposing for us. Would they like their health care insurance program repealed and gradually replaced? Would they enjoy health savings accounts? If they were not re-elected, they might need to seek another job. Would they want their pre-existing conditions to possibly not be covered by their next insurer?
BARBARA ELER
New Milford, Conn.
To the Editor: It's the height of hypocrisy for the House majority leader, Kevin McCarthy, to complain of Democrats ''playing politics'' with Obamacare and to call for good-faith negotiation. Republicans had the opportunity for this discussion in 2009 when President Obama articulated his openness to any proposal that expanded coverage without adding to the debt. They could readily have obtained many of the adjustments they now propose had they been willing to engage at that time. Instead they opted for calculated party-line opposition focused entirely on handing the president a political defeat, and outrageous anti-Obamacare hyperbole has poisoned the discussion in the years since.
By all means let's stop playing politics, but this means abandoning the overheated and vacuous repeal rhetoric and engaging in good-faith discussion on possible adjustments to the existing framework, not playing chicken with the coverage for millions of people.
STEVE LEOVY
Boulder, Colo.
To the Editor: ''Why It Will Be Hard to Repeal Obamacare'' (nytimes.com, Dec. 3) lays out the obstacles in undoing the Affordable Care Act. It explains how the G.O.P.'s restructuring of Obamacare could bring chaos to America's health insurance industry, not to mention the millions of Americans whose health and quality of life would be compromised.
Chaos doesn't come cheap. The operational costs alone to implement the changes bandied about by Speaker Paul Ryan and Tom Price, the nominee to head Health and Human Services, would be staggering. Every state would be affected, many of which are still upgrading their state-funded and federally subsidized programs to accommodate Obamacare policies.
A bit of prognostication: Since Paul Ryan's ''repeal and replace'' approach to Obamacare has morphed into ''repeal and delay,'' the ''repeal'' bills will pass easily in both the Senate and the House. But the Republicans are nowhere near coming up with the ''replace'' part. Congressional Democrats, in contrast to the last eight years, will and should be the obstructionists.
RICH AVILLA
Sequim, Wash.
The writer has been an analyst and senior consultant on state Medicaid programs and federal projects with the Center for Medicare and Medicaid Services.
To the Editor: From the start it's been clear that the best-known and most valued parts of Obamacare are (A) features like prohibiting penalties for pre-existing conditions and allowing people to remain on their parents' policies until age 26.
It's been equally clear that the most troublesome parts are (B) forcing people to buy health insurance, paying for the subsidies the system requires and keeping health care costs down.
So the Democrats will get credit for (A), provisions that are now too popular for the Republicans to repeal, while the Republicans in their pending health care redesign will be saddled with the problems that (B) will entail. Chalk one up for President Obama.
ANTHONY M. PAUL
Coral Gables, Fla.
To the Editor: There is a simple solution to the Republican quandary over repealing Obamacare while keeping many of its provisions: Pass a law renaming it Trumpcare. Problem solved.
CLAUDE FISCHER
Berkeley, Calif.
Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter.
URL: http://www.nytimes.com/2016/12/10/opinion/sunday/health-care-under-donald-trump.html
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October 13, 2011 Thursday
California Health Insurer Will Issue Refunds
BYLINE: REED ABELSON
SECTION: HEALTH
LENGTH: 339 words
HIGHLIGHT: The state's Blue Shield said it had pledged to cap profits at 2 percent.
Blue Shield of California, a large nonprofit health insurer based in San Francisco, said on Thursday that it planned to return an additional $295 million to its customers as part of the pledge it made earlier this year to cap its earnings to 2 percent of its revenue.
"We know this is a time that people are struggling paycheck to paycheck," said Bruce Bodaken, the insurer's chairman and chief executive, in a telephone interview. He said the insurer planned to refund the money in December. An average family of four will be credited about $420, according to the press release.
Last June, when the insurer first announced its pledge to cap profits, Blue Shield returned $180 million to its customers, largely through refunds to its policyholders.
The December refund represents the insurer's estimate for what it needs to give back in 2011 after deducting the 2 percent level of profits. June's refund represented the amount it said it would give back in 2010. Policyholders "are going to see every dime in their pocket," said Mr. Bodaken.
Like many nonprofit insurers, Blue Shield has come under sharp criticism for seeking large premium increases and for maintaining overly generous reserves. The federal health care law is aimed at trying to make sure insurers do not price premiums too much above the cost of paying for the care of their customers, and the White House was quick to note Blue Shield's action on a blog post on Thursday.
"Before the Affordable Care Act became law, many insurance companies could raise your premiums without any transparency or accountability," wrote Nancy-Ann DeParle, assistant to the president and deputy chief of staff for policy. "If you wanted to know why your rates were going up, they were under no obligation to tell you."
While Ms. DeParle goes on to cite some other examples, have you seen any relief from rates this year?
Blue Shield of California Vows to Cap Profits
Health Insurers Keep Reporting Robust Profits
If It Walks Like an Insurer ...
How to Mend Medicare
This Week's Health Industry News
LOAD-DATE: October 13, 2011
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The Biggest Changes Obamacare Made, and Those That May Disappear;
Public Health
BYLINE: MARGOT SANGER-KATZ
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HIGHLIGHT: A Republican bill to repeal the Affordable Care Act would roll back elements of the law but wouldn't erase the whole thing.
It looks like the beginning of the end for Obamacare as we know it.
After years of vowing to repeal the Affordable Care Act, as it is formally known, Republican lawmakers in both chambers of Congress have now passed a bill that will make it easier to gut the law.
Because they are using a special budget process, Republicans won't be able to repeal all provisionsof the health law. But it seems like a good time to look at the major changes Obamacare brought to health care, which of those changes may now disappear, and what might replace them.
An important note: We still don't know the details of a repeal bill, and passage is not guaranteed. But Republicans passed a similar package in 2015, vetoed by President Obama, that provides a rough template. Republicans have also said they hope to make further changes through additional legislation. We'll provide updates when new legislative language arrives, expected in several weeks.
1) Obamacare insured millions through new insurance markets.
The health law reduced the number of uninsured Americans by an estimated 20 million people from 2010 to 2016. One of the primary ways it did so was by creating online markets where people who didn't get insurance through work or the government could shop for a health plan from a private insurer. The law offered subsidies for Americans with lower incomes to help pay their premiums and deductibles.
What would happen? The Republican bill is expected to eliminate the subsidies. This would make insurance unaffordable for millions of Americans and sharply reduce the number who buy their own health coverage.
With many fewer people buying coverage, the insurance markets are likely to become increasingly unstable. Many insurers will stop offering policies, and the remaining customers are likely to be sicker than current Obamacare buyers, a reality that will drive up the cost of insurance for everyone who buys it, and force more people out of the markets. The Urban Institute estimates that the change would cause a total of 22.5 million people to lose their health insurance.
What might replace it? Separate legislation may include some new form of subsidy to help people afford insurance. Plans from House Speaker Paul Ryan and the budget committee chairman Tom Price, President-elect Donald J. Trump's pick to lead the Department of Health and Human Services, would both offer a flat tax credit to help buy insurance that varies by age. A proposal from the House Republican Study Committee would give all Americans a standard tax deduction to buy insurance.
2) Obamacare insured millions more by expanding Medicaid.
The health law provided federal funds for states to offer Medicaid coverage to anyone earning less than about $16,000 for a single person or $33,000 for a family of four. Not every state chose to expand, but most did.
What would happen? The Republican plan is expected to eliminate federal funding for the expansion. An estimated 12.9 million people would lose Medicaid coverage, according to the Urban Institute's projections.
What might replace it? Republican leaders have discussed reforming the remaining Medicaid program to give states more autonomy and to reduce future federal investment.
3) Obamacare established consumer protections for health insurance.
One of the law's signature features prevents insurance companies from denying coverage or charging a higher price to someone with a pre-existing health problem. The law included a host of other protections for all health plans: a ban on setting a lifetime limit on how much an insurer has to pay to cover someone; a requirement that insurers offer a minimum package of benefits; a guarantee that preventive health services be covered without a co-payment; a cap on insurance company profits; and limits on how much more insurers can charge older people than younger people. The law also required insurance plans to allow adult children to stay on their parents' policies until age 26.
What would happen? These rules can't be changed using the special budget process, so they would stay in place for now. But eliminating some of the other provisions, like the subsidies, and leaving the insurance rules could create turmoil in the insurance markets, since sick customers would have a much stronger incentive to stay covered when premiums rise. .
What might replace it? Mr. Trump has said that he'd like to keep the law's policies on pre-existing conditions and family coverage for young adults, but Senate Republicans recently voted against nonbinding resolutions to preserve those measures, suggesting they may be less committed. Some of the other provisions would probably be on the table if there were new legislation. Republicans in Congress would probably eliminate rules that require a minimum package of benefits for all insurance plans and allow states to determine what insurers would have to include. Mr. Trump has said he'd like to encourage the sale of insurance across state lines, a policy likely to make coverage more skimpy but less expensive for many customers. Republicans would also like to expand tax incentives for people to save money for health expenses.
Many of the Republican proposals would also establish so-called high-risk pools, which would provide subsidized insurance options for people with chronic health problems who wouldn't be able to buy insurance without rules forcing insurers to sell them coverage.
4) Obamacare required individuals to have health insurance and companies to offer it to their workers.
To ensure that enough healthy people entered insurance markets, the law included mandates to encourage broader coverage. Large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance, could be charged a tax penalty.
What would happen? The bill is expected to eliminate the mandates. Some experts think that eliminating the individual mandate, in particular, could destabilize insurance markets by reducing incentives for healthy people to buy coverage. The mandate had less of an impact on the employers, which had already been offering coverage.
What might replace it? Some Republican plans would allow insurers to charge much higher rates to customers who allow their coverage to lapse than to those who renew their policies every year. Such a system might provide a different financial incentive for healthy people to stay insured.
5) Obamacare raised taxes related to high incomes, prescription drugs, medical devices and health insurance.
To help pay for the law's coverage expansion, it raised taxes on several players in the health industry and on high-income earners.
What would happen? The G.O.P. package may roll back those tax increases, though there is some disagreement among Republican lawmakers about the deficit impact of such changes.
What might replace it? Republicans have not discussed raising new taxes to replace those in the Affordable Care Act. But some of their plans would limit the tax benefits offered to people who get their health insurance through work. That change would increase tax revenues, but would increase the cost of health insurance for many people who get it through work.
6) Obamacare made major reforms to Medicare payments.
The law cut the annual pay raises Medicare gives hospitals and reduced the fees Medicare pays private insurance companies. It created new incentives for hospitals and doctors to improve quality. It also set up a special office to run experiments in how Medicare pays doctors and hospitals for health care services. Those experiments are now widespread and have begun changing the way medicine is practiced in some places.
What would happen? The new legislation is expected to leave these changes alone, even though many have come under criticism by Republicans in Congress over the years, including from Mr. Price, an orthopedic surgeon. Many of the experiments could be reshaped or eliminated through regulation or through a future budget process.
What might replace it? Republicans in Congress have long talked about even more ambitious changes to Medicare, intended to move more beneficiaries into private insurance coverage. Mr. Trump has said that he does not want to make major changes to Medicare, so it is unclear if such a proposal would move forward.
7) Obamacare made many smaller changes that will probably last.
Obamacare had a range of policies meant to improve health and health care, including requirements that drug companies report payments made to physicians, a provision written by the Iowa senator Chuck Grassley, a Republican; a requirement that chain restaurants publish calorie counts on their menus; and a rule that large employers must provide a space for women to express breast milk.
What would happen? When Republicans talk about repealing Obamacare, they tend to focus on the parts of the law that expanded insurance coverage and regulated health insurance products, not these ancillary parts. That means that portions of the Affordable Care Act that people don't associate with the word "Obamacare" are likely to endure.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
Reed Abelson contributed reporting
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April 28, 2017 Friday
Late Edition - Final
Health Law Repeal Will Miss Trump's 100-Day Target Date
BYLINE: By THOMAS KAPLAN and ROBERT PEAR; Maggie Haberman contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1299 words
WASHINGTON -- An 11th-hour White House push to give President Trump a major legislative victory in his first 100 days in office broke down late Thursday as House Republican leaders failed to round up enough votes for their bill to repeal the Affordable Care Act.
Some White House officials had hoped for a vote on Friday on a measure to prove that Mr. Trump was making good on his promise to undo the sweeping health law -- President Barack Obama's signature domestic achievement -- in his first 100 days in office.
But seesawing commitments and the reservations from numerous lawmakers throughout Thursday laid bare the difficulty that Republican leaders faced in trying to push through a repeal bill. While revisions to their bill won over conservative hard-liners in the Freedom Caucus this week, those same changes threatened to drive away other members, even some who supported the first version.
A senior House aide said late Thursday that there would not be a vote on the health bill this week. At least 18 House Republicans oppose the latest version of the bill, the American Health Care Act, and leaders can lose no more than 22 to win passage if all members vote.
''We're going to try and measure three times and saw once,'' Representative Pete Sessions, Republican of Texas and the chairman of the House Rules Committee, said late Thursday. ''A lot of people around this town have tried their best to try and rush it, rush it, rush it.''
He urged patience, saying the health bill ''will find its time.''
The lost opportunity was perhaps the biggest blow to the future prospects of Reince Priebus, Mr. Trump's chief of staff, who has a long relationship with Speaker Paul D. Ryan of Wisconsin. Mr. Priebus had pushed aggressively for the House to schedule a vote this week, according to several people who spoke with him within the West Wing and on Capitol Hill.
Earlier on Thursday, Mr. Ryan appeared to shy away from pushing for a fast vote. ''We're going to go when we have the votes,'' he said, adding that Republicans would not be constrained by ''some artificial deadline.''
House Democrats, sensing an advantage, pressured Republicans to once again back away from the bill, just as they did a month ago in an embarrassing defeat for Mr. Trump and Mr. Ryan. Democratic leaders threatened to withhold votes from a stopgap spending measure to keep the government open past Friday if Republicans insisted on trying to jam the health care bill through the House on Friday or Saturday, which is Mr. Trump's 100th day as president.
The House Democratic leader, Nancy Pelosi of California, said Mr. Trump was ''really making fools of the members of Congress of his own party'' by asking them to support a health bill that is unpopular with the public.
''If they vote on it, the minute they cast that vote, they put doo-doo on their shoe,'' she said.
Republican leaders in both chambers plan to pass the stopgap measure to give lawmakers another week to work out a spending package to fund the government for the remainder of the fiscal year, which ends Sept. 30.
The longer-term spending deal is expected to provide more funding for the military and for border security, although Mr. Trump backed off his demand that lawmakers provide money for the wall he wants to build along the border with Mexico.
Mr. Ryan brushed off the threat from Democrats. ''I would be shocked that they would want to see a government shutdown,'' he said.
But Mr. Trump was not so dismissive. He unleashed a torrent of Twitter posts on Thursday accusing Democrats of wanting to shut down the government. The posts accused Democrats of putting the needs of health insurance companies, Puerto Rico and undocumented immigrants over the military, visitors to national parks and coal miners -- claims that Democrats called absurd.
The latest House plan to repeal and replace the health law would include an amendment drafted by Representative Tom MacArthur, Republican of New Jersey and a leader of a centrist bloc of lawmakers called the Tuesday Group.
Mr. MacArthur's amendment would allow states to opt out of certain provisions of the Affordable Care Act, including one that requires insurers to provide a minimum set of health benefits and another that prohibits insurers from charging higher premiums based on a person's health status.
Republicans say the federal mandates drive up costs, but Democrats say they provide important protections for consumers.
Under Mr. MacArthur's amendment, states could obtain waivers letting them redefine the ''essential health benefits,'' which now include maternity care, emergency services, mental health care and drug addiction treatment.
Republicans say their bill maintains protections for people with pre-existing conditions. But Democrats say the waivers would severely weaken these protections because insurers could charge higher premiums to sick people who wanted to buy insurance after a gap in coverage.
Republicans say their bill offers billions of dollars that states could use to operate high-risk pools or other programs to provide or subsidize insurance for people with pre-existing conditions.
The American Medical Association and AARP, the lobby for older Americans, oppose the latest version of the Republicans' health care bill.
''Although the MacArthur amendment states that the ban on pre-existing conditions remains intact, this assurance may be illusory, as status underwriting could effectively make coverage completely unaffordable to people with pre-existing conditions,'' said Dr. James L. Madara, the chief executive of the American Medical Association.
Mr. MacArthur said Thursday that his amendment had won over some of his Republican colleagues, though not enough to pass the bill. ''But we are closer today than we've ever been,'' he said. ''We're getting there.''
At the same time, his amendment highlighted the gulf between hard-line conservatives and more moderate Republicans when it comes to how to go about repealing and replacing the Affordable Care Act.
For the Freedom Caucus, which shouldered much of the blame for the House bill's failure last month, the amendment functioned as a way to shift any finger-pointing to a different bloc of members.
But the latest version of the House bill seemed to offer little that would entice anyone with reservations other than the hard-line conservatives.
''The proposed changes to this bill would leave too many of my constituents with pre-existing conditions paying more for health insurance coverage, and too many of them will even be left without any coverage at all,'' Representative Ileana Ros-Lehtinen, Republican of Florida, said Thursday.
It also gave pause to some Republicans who were ready to vote in favor of the measure last month.
Representative Mario Diaz-Balart, Republican of Florida, planned to support the bill last month before it was pulled. But on Thursday, he acknowledged ''a lot of red flags,'' including what would happen to people with pre-existing conditions. ''How are they treated?'' he asked. ''What options do they have?''
The House plan had already faced deep skepticism in the Senate, where other policy concerns are certain to be debated, like the future of Medicaid in states that expanded eligibility under the Affordable Care Act.
The Senate Democratic leader, Chuck Schumer of New York, argued on Thursday that the core of Mr. MacArthur's amendment would violate the budget rules that Republicans must follow in order to sidestep a Democratic filibuster.
Mr. Schumer warned House Republicans against voting for a flawed bill ''to save face for the president in the first 100 days.''
''Why,'' he asked, ''would you risk voting yes for a bill that is devastating to your constituents and has no chance of becoming law?''
URL: https://www.nytimes.com/2017/04/27/us/politics/republicans-propose-short-term-funding-plan-to-avert-shutdown.html
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GRAPHIC: PHOTOS: Speaker Paul D. Ryan, above, said the House would vote on the new health care bill ''when we have the votes.'' Chuck Schumer, left, the Senate Democratic leader, warned Republicans against voting for a flawed bill ''to save face for the president.'' (PHOTOGRAPHS BY GABRIELLA DEMCZUK FOR THE NEW YORK TIMES
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June 2, 2014 Monday
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The Vanishing Cry of 'Repeal It'
BYLINE: By THE EDITORIAL BOARD
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LENGTH: 597 words
It was supposed to be so easy this election year for Republican congressional candidates. All they would have to do was shout ''repeal Obamacare!'' and make a crack about government doctors and broken websites, and they could coast into office on a wave of public fury. The failure of the Affordable Care Act was simply assumed.
But it has not quite worked out that way. The government website was fixed, and 8.1 million people managed to sign up for insurance through the exchanges. An additional 4.8 million people received coverage through Medicaid and the Children's Health Insurance Program. Three million people under the age of 26 were covered by their parents' plans. Though the law itself has never been widely popular, most people say they like its component parts, and a large majority now says it wants the law improved rather than repealed.
That sentiment conflicts with the Republican playbook, which party leaders are suddenly trying to rewrite. The result has been an incoherent mishmash of positions, as candidates try to straddle a widening gap between blind hatred of health reform and the public's growing recognition that much of it is working.
Sometimes the dissonance reaches nearly comic levels. The Senate minority leader, Mitch McConnell, recently won his party's primary for his Kentucky Senate seat in part by saying he wanted to repeal the health law ''root and branch.'' Last week, though, he was asked what repeal would mean for the 413,000 people who had signed up for insurance under Kynect, Kentucky's state-run exchange. ''I think that's unconnected to my comments about the overall question,'' he said. Mr. McConnell knows full well, of course, that the popular Kynect program was created by the Affordable Care Act and could not exist without it, but he is hoping to fool his constituents into believing the health care access they like has nothing to do with the law he has fought against for so long or with President Obama.
His campaign even suggested he would allow many of the 300,000 Kentuckians who signed up for Medicaid -- solely because of the law's expansion -- to stay covered after repeal, which makes about as much sense as his previous statement.
Many other Republican candidates have also switched from brimstone to mush on the issue, no longer claiming they will repeal the law but instead will ''replace'' it or ''fix'' it in some unspecified way that could not possibly work. An example is an ad from the United States Chamber of Commerce in support of Richard Tisei, a Republican running for a Massachusetts congressional seat, which promises that he would work in a ''bipartisan manner to fix health care the right way.''
And just what is that right way? ''He wants to instill free-market solutions,'' the ad says, ''end the job-killing tax on medical devices and curb lawsuit abuse to bring down the cost of care.'' None of which has anything to do with bringing care to the uninsured, or those with pre-existing conditions.
Scott Brown, who failed to sell this kind of nonsense in the Senate race in Massachusetts in 2012, is now peddling it in New Hampshire, where he is running for the Senate by saying the health law is ''hurting families.'' But not his family, apparently; in 2012, he admitted to keeping his daughter, then 23, on his policy, thanks to the law.
The good news is that some Democratic candidates, sensing the same change in the weather, are beginning to campaign on the law's benefits. Improving access to health care was the right thing for the country, and supporting it may turn out to be good politics, too.
URL: http://www.nytimes.com/2014/06/02/opinion/the-vanishing-cry-of-repeal-it.html
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October 3, 2015 Saturday
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The Candidates on Health Care
BYLINE: By THE EDITORIAL BOARD
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LENGTH: 522 words
While the Republican presidential candidates have been busy railing against Obamacare, the two leading contenders for the Democratic nomination have staked out radically different ideas on how to improve the American health care system.
Hillary Rodham Clinton has proposed adding useful consumer protections to the Affordable Care Act. Senator Bernie Sanders wants to create a single-payer system that would essentially expand Medicare to cover people of all ages.
Senator Sanders's bold call for ''a fundamental transformation of the American health care system'' would look more like the plans in many other industrialized nations that often achieve better health outcomes at lower costs. His home state of Vermont flirted with the idea, but it dropped its plans because of fears that the high costs would harm the economy. A national program could be more cost-effective, but it has no chance of surmounting opposition from Republicans and from health care industries that fear their profits would be cut.
Mrs. Clinton vigorously defends the Affordable Care Act and its reliance on private insurance, but she would make important changes to protect people from co-payments and deductibles that have been rising faster than their wages. She would create a new tax credit of up to $5,000 to help families pay high out-of-pocket medical costs and would require insurers to cover three visits to the doctor each year before people start paying to meet their deductible.
Both Mrs. Clinton and Mr. Sanders have taken strong stands against the sometimes exorbitant prices for prescription drugs that manufacturers set with no reasonable justification. Both would authorize Medicare to negotiate with drug companies to drive down prices -- a move now prohibited by law, at Republican insistence -- and both would allow Americans to import cheaper drugs from other countries. Mrs. Clinton would cap a patient's out-of-pocket drug spending at $250 a month.
The leading Republican candidates are unanimous in calling for repeal of the health care reform law -- Donald Trump has called it a ''catastrophe,'' and Jeb Bush labeled it a ''monstrosity.'' Yet they are remarkably tongue-tied on how they would replace it.
In the Sept. 16 debate among 11 Republican candidates, the issue came up only obliquely. None of the Republican candidates have endorsed government negotiations with drug companies; they believe private negotiations and competition among drug companies are working just fine to curb drug costs.
Of the Republicans, only Senator Marco Rubio has sketched out an alternative to the current health system. He would rely on tax credits of unspecified amounts to help people buy private insurance -- an approach that is comparable to what the Affordable Care Act does now but that would most likely be less generous. He needs to flesh out his plans and his competitors need to devise serious alternatives of their own so that voters can see how they compare with a reform law that is working remarkably well.
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URL: http://www.nytimes.com/2015/10/03/opinion/the-candidates-on-health-care.html
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March 28, 2016 Monday
The New York Times on the Web
On Campaign Trail, Republicans Tone Down Criticism of Obamacare
BYLINE: By ALBERT R. HUNT | BLOOMBERG VIEW
SECTION: Section ; Column 0; National Desk; LETTER FROM WASHINGTON; Pg.
LENGTH: 689 words
No issue has aroused more partisan passion over the past six years than the Affordable Care Act. Yet the law is playing only a secondary role in the American elections.
Sure, Republican presidential candidates cater to their base by vowing to repeal and replace ''Obamacare,'' and on the Democratic side, Senator Bernie Sanders of Vermont promises to replace it with a government-run universal coverage system.
But it doesn't dominate the dialogue and isn't a top priority on either side. Among the most embattled Senate Republican incumbents, the campaign websites of Kelly Ayotte of New Hampshire, Mark Kirk of Illinois and Ron Johnson of Wisconsin barely mention the health care law. . An exception is Pat Toomey of Pennsylvania.
The explanation may be that for all its controversy and imperfections, the sweeping law has taken hold. ''This is in the fabric of the nation,'' said Health and Human Services Secretary Sylvia Mathews Burwell.
To be sure, the presidential election outcome will be a determinant of whether the health care law is reshaped, bolstered or downsized.
But even some skeptics acknowledge that its numbers are rather impressive. About 20 million more Americans now have health insurance than before the law was enacted in 2010; in the last enrollment period on the health care exchanges, 12.7 million signed up and almost 40 percent were newcomers. The expansion of Medicaid for the poor is making a mark.
Millions of Americans with pre-existing conditions no longer can be denied coverage, children can stay on their parents' plans until age 26, and health care inflation is the lowest in years.
Ms. Burwell, in an interview, noted that there are a lot of lesser-known successes, such as a sharp reduction in patients being harmed in hospitals. She acknowledges challenges, which she put in ''three buckets'': reforming the health care delivery system to encourage quality, not quantity, of care; addressing a few places where the health insurance markets still are broken, such as Alaska; and making technical fixes so the law works a little better.
Critics find more challenges. Premiums have soared this year in a number of states. Congress, in a bipartisan move, postponed and is threatening to kill a couple important provisions that could create budgetary and cost control problems. And 22 states where Republicans hold sway have refused the expansion of Medicaid coverage.
In the presidential campaign, the rhetoric still can get hot. Senator Ted Cruz of Texas says the Affordable Care Act is ''the biggest job killer in this country. Millions of Americans have lost their jobs.'' (Over all, from March 2010, when the law was enacted, until today, the economy has added 13.7 million jobs.)
But most Republicans insist that they would keep popular provisions such as guaranteeing coverage for people with pre-existing conditions. Gov. John Kasich embraced the law's expansion of Medicaid in Ohio. The Republican front-runner, Donald J. Trump, has said he likes the mandate to get health insurance -- the centerpiece of the act and chief target of most conservative critics -- and that he would not let people ''die sitting in the middle of the street.''
When speculation surfaced that Mr. Trump and Gov. Kasich could run together, the conservative Weekly Standard lamented that it would be ''the nightmare ticket for opponents of Obamacare.''
If the Republicans win in November, however, even Mr. Trump would have to try to dismantle the law, given how important that is to the party's base. The targets for action could include the Medicaid expansion; the mandate requiring health insurance (by replacing it with some other program); and subsidies introduced under the law. The problem is that millions of newly insured people would probably lose coverage, which could create a political backlash.
If Hillary Clinton is elected, she also would probably make changes to buttress the Affordable Care Act. The emphasis likely would be on cost controls.
The health care law may not play much of a role in the outcome of this presidential election, but the partisan controversy has not gone away.
URL: http://www.nytimes.com/2016/03/28/us/on-campaign-trail-republicans-tone-down-criticism-of-obamacare.html
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November 10, 2014 Monday
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Death by Typo
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 21
LENGTH: 798 words
My parents used to own a small house with a large backyard, in which my mother cultivated a beautiful garden. At some point, however -- I don't remember why -- my father looked at the official deed defining their property, and received a shock. According to the text, the Krugman lot wasn't a rough rectangle; it was a triangle more than a hundred feet long but only around a yard wide at the base.
On examination, it was clear what had happened: Whoever wrote down the lot's description had somehow skipped a clause. And of course the town clerk fixed the language. After all, it would have been ludicrous and cruel to take away most of my parents' property on the basis of sloppy drafting, when the drafters' intention was perfectly clear.
But it now appears possible that the Supreme Court may be willing to deprive millions of Americans of health care on the basis of an equally obvious typo. And if you think this possibility has anything to do with serious legal reasoning, as opposed to rabid partisanship, I have a long, skinny, unbuildable piece of land you might want to buy.
Last week the court shocked many observers by saying that it was willing to hear a case claiming that the wording of one clause in the Affordable Care Act sets drastic limits on subsidies to Americans who buy health insurance. It's a ridiculous claim; not only is it clear from everything else in the act that there was no intention to set such limits, you can ask the people who drafted the law what they intended, and it wasn't what the plaintiffs claim. But the fact that the suit is ridiculous is no guarantee that it won't succeed -- not in an environment in which all too many Republican judges have made it clear that partisan loyalty trumps respect for the rule of law.
To understand the issue, you need to understand the structure of health reform. The Affordable Care Act tries to establish more-or-less universal coverage through a ''three-legged stool'' of policies, all of which are needed to make the system work. First, insurance companies are no longer allowed to discriminate against Americans based on their medical history, so that they can't deny coverage or impose exorbitant premiums on people with pre-existing conditions. Second, everyone is required to buy insurance, to ensure that the healthy don't wait until they get sick to join up. Finally, there are subsidies to lower-income Americans to make the insurance they're required to buy affordable.
Just as an aside, so far this system seems to be working very well. Enrollment is running above expectations, premiums well below, and more insurance companies are flocking to the market.
So what's the problem? To receive subsidies, Americans must buy insurance through so-called exchanges, government-run marketplaces. These exchanges, in turn, take two forms. Many states have chosen to run their own exchanges, like Covered California or Kentucky's Kynect. Other states, however -- mainly those under G.O.P. control -- have refused to take an active role in insuring the uninsured, and defaulted to exchanges run by the federal government (which are working well now that the original software problems have been resolved).
But if you look at the specific language authorizing those subsidies, it could be taken -- by an incredibly hostile reader -- to say that they're available only to Americans using state-run exchanges, not to those using the federal exchanges.
As I said, everything else in the act makes it clear that this was not the drafters' intention, and in any case you can ask them directly, and they'll tell you that this was nothing but sloppy language. Furthermore, the consequences if the suit were to prevail would be grotesque. States like California that run their own exchanges would be unaffected. But in places like New Jersey, where G.O.P. politicians refused to take a role, premiums would soar, healthy individuals would drop out, and health reform would go into a death spiral. (And since many people would lose crucial, lifesaving coverage, the deaths wouldn't be just a metaphor.)
Now, states could avoid this death spiral by establishing exchanges -- which might involve nothing more than setting up links to the federal exchange. But how did we get to this point?
Once upon a time, this lawsuit would have been literally laughed out of court. Instead, however, it has actually been upheld in some lower courts, on straight party-line votes -- and the willingness of the Supremes to hear it is a bad omen.
So let's be clear about what's happening here. Judges who support this cruel absurdity aren't stupid; they know what they're doing. What they are, instead, is corrupt, willing to pervert the law to serve political masters. And what we'll find out in the months ahead is how deep the corruption goes.
URL: http://www.nytimes.com/2014/11/10/opinion/paul-krugman-the-latest-frivolous-attack-on-obamacare.html
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August 15, 2012 Wednesday
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Obama-Ryan Battle Intensifies Over Medicare Savings
BYLINE: By ROBERT PEAR
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LENGTH: 876 words
WASHINGTON -- Representative Paul D. Ryan's budget blueprint assumes the same amount of Medicare savings as President Obama's health care law, even though Mitt Romney and Mr. Ryan have said those cuts would be devastating to millions of older Americans on Medicare.As the partisan brawl over Medicare continued on Tuesday and threatened to become the focus of the race, the Obama campaign said that Mr. Ryan's budget plan -- broadly endorsed by Mr. Romney -- ''would end Medicare as we know it'' and shift costs to beneficiaries.
The Republicans hit back on Tuesday with a television commercial asserting that the Romney-Ryan Medicare plan was better for older Americans.
''You paid into Medicare for years, every paycheck,'' the advertisement says. ''Now when you need it, Obama has cut $716 billion from Medicare. Why? To pay for Obamacare. So now the money you paid for your guaranteed health care is going to a massive new government program that's not for you.''
Lis Smith, a spokeswoman for the Obama campaign, said, ''Mitt Romney's Medicare ad is dishonest and hypocritical.'' The savings, she said, ''do not cut a single guaranteed Medicare benefit.''
In an interview with Fox News on Tuesday, Mr. Ryan said he welcomed the back and forth.
''This is a debate we want to have,'' he said. ''We're the ones who are offering a plan to save Medicare, to protect Medicare, to strengthen Medicare.''
With 50 million beneficiaries, Medicare is a major concern for both parties. The current fight centers on changes in the program made in the new health law, the Affordable Care Act, passed in 2010 without Republican votes.
Mr. Obama would use the savings to help offset the cost of covering the uninsured, as well as to improve the financial condition of the Medicare trust fund. Mr. Ryan says he would use the money to shore up Medicare and to help reduce budget deficits.
Republicans won control of the House in 2010 partly by arguing that Democrats had raided Medicare to pay for Mr. Obama's health care law. Democrats hope to deflect such attacks this year by pointing out that Mr. Ryan's budget plan, approved twice by the House, includes similar savings -- roughly $700 billion from 2013 to 2022, according to the Congressional Budget Office.
Those savings have a complicated history.
Mr. Ryan's budget plan was approved in March by the House Budget Committee, of which he is chairman. Before the vote, committee members discussed the budget plan and the Medicare provisions in detail.
Representative Allyson Y. Schwartz, Democrat of Pennsylvania, asked whether the savings in the Affordable Care Act -- ''sometimes referred to as cuts to Medicare'' -- were part of Mr. Ryan's budget.
Austin Smythe, the panel's Republican staff director, said: ''We assume those savings. We devote them to solvency of Medicare and to deficit reduction, instead of covering the expansions.''
At another point, Mr. Smythe said, ''We assume the repeal of all of the expansions in the Affordable Care Act.''
Those expansions, he said, include subsidies to help low- and middle-income people buy private insurance. Democrats said that repeal of the new law would also wipe out new Medicare benefits, like additional coverage of prescription drugs and preventive services.
The House approved the Ryan budget plan on March 29 by a vote of 228 to 191, with all but 10 Republicans voting for it.
Mr. Romney has offered a Medicare proposal similar to Mr. Ryan's. But the Romney campaign said Tuesday that Mr. Romney would restore the money being squeezed out of Medicare by the 2010 health law.
''Mitt Romney and Paul Ryan have always been fully committed to repealing Obamacare, ending President Obama's $716 billion raid on Medicare, and tackling the serious fiscal challenges our country faces,'' said Lanhee Chen, the policy director for the Romney campaign. ''A Romney-Ryan administration will restore the funding to Medicare.''
The Ryan plan, like any budget resolution, specifies levels of spending, savings and revenues, based on certain policy assumptions. But, as Mr. Smythe pointed out, ''the committees of jurisdiction determine the details'' in separate legislation.
Mr. Ryan and Mr. Obama would impose similar overall constraints on Medicare spending, stipulating that average spending per beneficiary should not grow faster than the economy, measured by the per capita output of goods and services, plus one-half of one percentage point.
However, they would achieve the goal in different ways.
Mr. Ryan and Mr. Romney would limit the government's current open-ended financial commitment to Medicare. The government would contribute a fixed amount of money on behalf of each beneficiary, and future beneficiaries could use the money to buy private insurance or to help pay for coverage under the traditional Medicare program.
The new health care law, by contrast, will reduce projected Medicare payments to health maintenance organizations, hospitals and many other health care providers. As a backstop, to ensure savings, the law creates a Medicare cost control board. Cuts recommended by the board would take effect automatically unless Congress voted to block or change them.
Mr. Romney and Mr. Ryan would abolish the panel, which they describe as a tool for rationing health care.
URL: http://www.nytimes.com/2012/08/15/health/policy/battle-over-medicare-savings-intensifies-between-obama-and-paul-ryan.html
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The New York Times
March 9, 2017 Thursday
Late Edition - Final
Republicans' Changes to Medicaid Could Have Larger Impact Than Their Changes to Obamacare
BYLINE: By HAEYOUN PARK
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 1028 words
House Republicans are proposing to fundamentally alter the way the federal government has been financing Medicaid for more than 50 years. The changes are part of their plan to replace the Affordable Care Act, also known as Obamacare. ''This is potentially more major than repealing the Affordable Care Act,'' said Joan Alker, the executive director of the Center for Children and Families at Georgetown University. Medicaid provides health insurance to 74 million people, or one in five Americans. Of the 20 million who gained insurance under Obamacare, at least half were through Medicaid expansion. The changes would not begin until 2020. But the long-term impact on states would be unequal, with some faring better than others, depending on how much they spent on the program, their demographics and whether they participated in President Barack Obama's expansion of Medicaid eligibility.
The Republican bill calls for capping how much the federal government gives each state per Medicaid enrollee, based on how much the state was spending on the program in 2016. Spending varies widely from state to state. Nevada and Georgia, for example, spend less than $4,500 per enrollee, while Massachusetts and New York spend more than $10,000 per enrollee.
Since it was created in 1965, federal funding for Medicaid grew as needs changed for the states. If more people became eligible, say, because of a recession, or if costs rose because of expensive new medicines or a public health crisis, states received more federal money. Federal spending on Medicaid flexes as states alter their policies, eligibility rules and payment rates for doctors, hospitals and nursing homes.
Under the Republican plan released on Monday, federal funding for every Medicaid beneficiary would essentially freeze, rising only with the medical component of the Consumer Price Index, or the price of medical care. That change would allow funding to grow if more people sign up for Medicaid, but not if the cost of care for Medicaid patients spikes, or states want to offer new benefits or increase payments to doctors. Some health experts worry that over time, states would be unable to respond to changes in the health care needs of their population unless they use their own money, potentially risking the survival of a program that has been a critical source of health coverage for the poor. ''I think of it as essentially putting states behind bars,'' said Sara Rosenbaum, a professor of health law and policy at George Washington University. ''Whatever you were doing circa 2016 is what you're going to do forever.'' Virginia, where the governor has declared its opioid crisis a public health emergency, recently decided to significantly expand the scope of its Medicaid benefits to spend more on drug treatment for patients. If there was a cap on federal funding, the state would not be able to share these cost increases -- beyond simple medical inflation -- with the federal government, Ms. Rosenbaum said. ''The core problem with aggregate limits, whether across the board or per capita, is that they're impervious to the factors that drive health care spending,'' she said. ''The potential effects are enormous.''
The Republican plan would set different spending targets for different types of Medicaid beneficiaries, like older Americans, blind and disabled people, children and adults. States with rapidly growing populations of older Americans, like Nevada and Arizona, may still be hit harder over time.
This is partly because spending for older Americans, along with disabled people, makes up a larger proportion of Medicaid spending, even though they are a smaller share of enrollment. Spending for that population is less likely than others to track the medical consumer price index, because much of the money tends to go to nursing home care, not traditional medical services.
Putting an end to the open-ended commitment from the federal government could create an incentive for states to drop their costliest populations, like older Americans, out of concern that their costs will grow faster than inflation, Ms. Rosenbaum said. In addition, people 85 and older have 2.5 times more Medicaid costs as people 65 to 74, according to Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group. So, if a state has more expensive people joining its mix, but the amount of money it gets from the federal government is fixed and grows slowly, states would have to pay the additional costs, Ms. Alker said.
In a shift from previous proposals, the Republican legislation does not immediately repeal Medicaid expansion. It allows states like Kentucky, Nevada and Colorado to continue receiving federal funding as they would have under Obamacare until 2020, delaying the potential impact on states that expanded Medicaid. Under Obamacare, 31 states and the District of Columbia expanded Medicaid to cover adults whose income was at or below 138 percent of the poverty line, covering millions of low-income Americans who previously found it difficult to afford insurance. Kentucky saw the largest growth in enrollment, though some recent enrollees were probably already eligible even before the expansion.
The federal government currently covers nearly all the costs of Medicaid enrollees who became eligible under the expansion. But in 2020, enrollment under the expansion would freeze, and if a state decided to continue enrolling new beneficiaries under the expansion criteria, it would have to pay more to do so. Enrollment could inevitably decline because Medicaid is a program where people go in and out over time, say, if they lose a job, for example. It is not yet clear how much savings the new plan would produce, but Republican leaders have long argued that fixing federal funding for Medicaid would ultimately produce significant savings in the federal budget while providing states more flexibility in managing the program. ''But states already have a lot of flexibility in Medicaid,'' Ms. Alker said.
This is a more complete version of the story than the one that appeared in print.
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CHARTS (Sources: Centers for Medicare & Medicaid Services
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(News)
June 26, 2015 Friday
Morning Agenda: Humana Said to Pursue Deal to Sell Itself
BYLINE: DEALBOOK
LENGTH: 1824 words
HIGHLIGHT: Humana Said to Pursue Deal to Sell Itself | Prison Term Sought for Email Hacker | Greek Bailout Talks Go Down to the Wire | Calpers’s Private Equity Fees Under Scrutiny
HUMANA SAID TO PURSUE DEAL TO SELL ITSELF | Humana, the smallest of the big five health insurers in the United States, could reach an agreement by next week to sell itself to another insurer, according to a person briefed on the matter, Michael J. de la Merced writes in DealBook. Among the suitors are Aetna and Cigna, which have both been the targets of takeovers themselves as insurance companies look to cut costs through consolidation and take advantage of the opportunities that are part of the Affordable Care Act.
"The machinations of Humana - set against a backdrop of frenzied merger discussions within the insurance industry - received an extra jolt from the Supreme Court's ruling on Thursday that the government could furnish tax subsidies for poor and middle-class Americans to buy health insurance," Mr. de la Merced writes. Humana is seen as an attractive acquisition because of its big presence in the Medicare market, which has benefited from the Affordable Care Act. Aetna, Anthem and Cigna all have relatively smaller Medicare Advantage businesses.
The company has been working with bankers at Goldman Sachs as it considers takeover offers, Mr. de la Merced writes. While Humana is perhaps the least expensive takeover target within the big five insurers, with a market value of $27.6 billion, it faces a few distinct issues. Among them is that its rival with the biggest financial resources, UnitedHealthcare, would most likely be barred by government regulators from buying Humana because both companies have major operations tied to Medicare.
PRISON TERM SOUGHT FOR EMAIL HACKER | On Friday, federal prosecutors are expected to seek a prison sentence of up to six months for Eric Saldarriaga, 41, a private investigator who hacked into emails on behalf of his clients, Matthew Goldstein writes in DealBook. Mr. Saldarriaga, who pleaded guilty on March 6 to one count of conspiracy to commit computer hacking, paid an unidentified overseas firm to secure the login credentials and passwords for the email accounts he wanted access to without permission.
He made only $5,000 from these hacking assignments, but Daniel S. Noble, a prosecutor working for Preet Bharara, the United States attorney in Manhattan, argued in a pre-sentencing memorandum that Mr. Saldarriaga's invasion of privacy warranted a stronger punishment than the six months of home detention and three years of supervised probation recommended by the court's own probation department. "Unlike defendants in a gun or drug case, who often act without reflection, there is reason to believe that individuals who engage in hacking and other forms of cybercrime can be deterred by a substantial threat of penalties," he wrote.
Mr. Saldarriaga has been the only one charged with a crime, even though some of those who hired him appear to have been aware of what he was doing. Mr. Saldarriaga's clients are known to have included lawyers, wealthy people and even other private investigators, people briefed on the matter told Mr. Goldstein. Some of the victims of Mr. Saldarriaga's email hacking, like Tony Ortega, a former editor of The Village Voice who has written about Scientology, have been pressing prosecutors to reveal the name of the clients.
GREEK BAILOUT TALKS GO DOWN TO THE WIRE | On Thursday, for the fourth time in a week, a meeting of the Eurogroup of eurozone finance ministers ended without resolution on a Greek bailout deal, James Kanter writes in The New York Times. The ministers only agreed to meet again, on Saturday. "It looks like both sides are going to walk this to the precipice," said Mujtaba Rahman, who heads the Europe practice for the Eurasia Group, a political-risk consultant firm. "But any deal that comes out of that is of course going to be more political and even more economically suboptimal."
One of the possible outcomes of Saturday's discussion could be a messy compromise that would extend the current bailout for a few more months but provide no additional aid until Greece fulfills certain conditions, Mr. Kanter writes. If that happens, Greece might be unable to pay the 1.6 billion euros, or $1.8 billion, that it owes the International Monetary Fund by Tuesday.
Another possibility is that Prime Minister Alexis Tsipras of Greece may be forced into a tough decision if creditors lose patience with him, said Megan E. Greene, the chief asset management economist for Manulife. Though the creditors' proposals are opposed by members of the prime minister's own party, Mr. Tsipras may have to choose between saving his country's banks and saving his government if the European Central Bank threatens to cut off emergency assistance, as it did with the Cypriot leadership in early 2013. "It could be a case of Mr. Tsipras being told, 'Pick up the pen and sign, or we blow up your banking sector," ' Ms. Greene said.
ON THE AGENDA | The University of Michigan's consumer sentiment index for June is released at 10 a.m. Esther George, the president of the Federal Reserve Bank of Kansas City and an alternate voting member of the Fed's policy-setting committee, speaks at a payments security conference in Kansas City, Mo., at 11:45 a.m. (12:45 E.D.T.).
CALPERS'S PRIVATE EQUITY FEES UNDER SCRUTINY | When a senior executive of the California Public Employees' Retirement System said in April that the country's biggest state pension fund did not know how much it paid in fees to private equity firms, the admission was received with skepticism by some, Alexandra Stevenson writes in DealBook. J. J. Jelincic, a member of the Calpers board, said, "I'm not sure I believe the staff when they say they don't know what the carry is," referring to carried interest, the industry term for private equity performance fees. Another skeptic is Edward A. H. Siedle, a pension fraud investigator and a former lawyer at the Securities and Exchange Commission, who is now hoping to raise $750,000 through the online platform Kickstarter to determine how much Calpers pays in private equity fees.
"The money manager knows to a penny what the fees are," Mr. Siedle said. "The only explanation is that the pension fund has chosen not to ask the question because, from an accounting and legal perspective, those numbers have to be readily available. They are intentionally not asking because if the fees were publicly disclosed, the public would scream." Calpers paid $1.6 billion in fees to Wall Street in 2014, according to its annual report. The figure, however, does not include how much it paid in carried interest. Both Mr. Siedle and Mr. Jelincic say that figure could be as much as an additional $1 billion a year.
Mergers & Acquisitions »
Valeant Said to Express Interest in Buying Zoetis | Valeant Pharmaceuticals International has made a preliminary approach to buy the animal vaccine maker Zoetis, The Wall Street Journal reports, citing people familiar with the matter.
THE WALL STREET JOURNAL
Potash Said to Offer 7.8 Billion Euros for German Rival | Potash Corporation of Saskatchewan offered to buy its German rival K&S AG for 7.8 billion euros, or $8.7 billion, The Wall Street Journal reports, citing a person familiar with the matter.
THE WALL STREET JOURNAL
Cinven Agrees to Buy a Majority Stake in Synlab | The European private equity firm will buy a controlling share in the German laboratory testing company, in a deal that values Synlab at about $2 billion.
NYT »
Charter Makes Its Case for 2 Mergers, Telling F.C.C. It's No Comcast | Charter wants to buy Time Warner Cable and Bright House. In an F.C.C. filing, it outlined why its ownership would be beneficial, all the while disassociating itself from Comcast's failed takeover.
NYT »
INVESTMENT BANKING »
China to Allow Creation of More Private Banks | China's banking regulator said on Friday that it will allow the establishment of more private banks and let foreign investors participate, Reuters reports.
REUTERS
Airbus Issues First Convertible Bond | Airbus said Friday that it was issuing its first convertible bonds, a deal worth as much as 500 million euros, or $560 million. The bonds are due in 2022 and bear a coupon of zero percent, The Financial Times reports.
THE FINANCIAL TIMES
Women's Struggles on Wall Street | Bloomberg Markets profiles three women poised to become the first woman to run a Wall Street firm - Karen B. Peetz of Bank of New York Mellon; Mary Callahan Erdoes of JPMorgan Chase; and Avid Modjtabai of Wells Fargo - and why they may never get there.
BLOOMBERG MARKETS
I.P.O./OFFERINGS »
I.P.O. to Give Operator of Match.com and Tinder Its Own Stock | The media conglomerate IAC/InterActiveCorp said it was planning an I.P.O. for the Match Group, its online dating business, which includes OkCupid.
NYT »
Europcar Shares Decline in Early Trading After Paris I.P.O. | The French rental car company sold about $985 million in an offering of 71.8 million shares, which was priced late Thursday.
NYT »
VENTURE CAPITAL »
Venture Capital Firm Formation 8 Creates Vehicle Focused on Asian Start-Ups | In a regulatory filing, Formation 8 said it would aim to raise up to $400 million for a special investment vehicle to finance new companies in Asia.
NYT »
Breakingviews: Palantir Technologies Intrigues Investors Despite Its Mysteries | The privately held Palantir is reported to be valued at $20 billion, but getting an accurate reading of its worth in the public markets seems unlikely.
Breakingviews »
Michael Wolff's New Book Celebrates the Success of Old Media | Michael Wolff's latest book is a thoughtful essay on the state of the cultural and financial wars besieging the media industry, Jonathan A. Knee writes in the Book Entry column.
Book Entry »
LEGAL/REGULATORY »
Jeb Hensarling's Fight Against Ex-Im Bank Succeeds, for the Moment | With Congress in its July 4 recess, there are no opportunities left to save the bank's charter before it expires - giving the divisive House chairman a temporary win.
NYT »
If Greece Defaults, Imagine Argentina, but Much Worse | The Greek debt crisis has similarities to Argentina's default in 2001. But experts say a default would be much worse for Greece, James B. Stewart writes in the Common Sense column.
Common Sense »
Chinese Stock Indexes Plunge | China's two major market indexes fell sharply on Friday. Analysts had been warning for months about the risks of a stock market bubble.
NYT »
Justices Back Broad Interpretation of Housing Law | The Supreme Court, in a 5-to-4 vote, endorsed a legal theory that civil rights groups say is crucial to fighting housing discrimination.
NYT »
France Files Legal Complaint Against UberPop | Bernard Cazeneuve, the French interior minister, said on Friday that he had filed a legal complaint against local managers of UberPop, denouncing the attitude of the company as "cynical" and "arrogant," Reuters reports.
REUTERS
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The New York Times
September 18, 2014 Thursday
Late Edition - Final
With New Health Law, Crucial Choices
BYLINE: By MARGOT SANGER-KATZ and AMANDA COX
SECTION: Section A; Column 0; National Desk; THE NEW HEALTH CARE; Pg. 3
LENGTH: 1605 words
If you bought health insurance at an Affordable Care Act marketplace this year, it really pays to look around before renewing your coverage for next year.
The system is set up to encourage people to renew the policies that they bought last year -- and there are clear advantages to doing so, such as being able to keep your current doctors. But an Upshot analysis of data from the McKinsey Center for U.S. Health System Reform shows that in many places premiums are going up by double-digit percentages within many of the most popular plans. But other plans, hoping to attract customers, are increasing their prices substantially less. In some markets, plans are even cutting prices.
The combination will create a dilemma for many people and highlights both a benefit and drawback of the new insurance marketplaces created by the health law. As the law's designers intended, plans are competing for customers, which often holds cost down. But all the jostling around in the market means that consumers are stuck with tough choices -- swallow a big premium increase or switch to a cheaper plan that may cover different doctors and hospitals.
''It's a nuanced story,'' said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health research group that is also tracking premium changes. ''You can still be protected, but it means you have to change plans.''
The McKinsey data is based on preliminary information about rates in 18 states and the District of Columbia.
Many of the cheapest marketplace plans provide access to a limited groups of doctors and hospitals. That means that, in a lot of places, switching plans will also mean switching doctors. Plans also differ in their benefit designs, meaning they may have different deductibles or co-payment structures.
The subsidies the federal government pays to low- and moderate-income households will decrease, on average, in 2015. But because of the way the Obama administration is processing renewals, many customers who don't shop may end up paying the wrong amount each month and getting a big bill (or refund) for the difference when they pay their federal income taxes.
You may have read what's happening with average premiums. But individual consumers don't buy the average plan. And the federal government doesn't pay for the average plan. Instead of looking at averages, we looked at three sets of numbers to give a clearer picture of what's happening in the marketplaces where data is currently available.
All of our numbers come from a category of plan called ''silver.'' To qualify as silver, a plan has to cover 70 percent of the average patient's medical costs. The marketplaces contain richer and skimpier categories, but silver plans were the most popular this year.
First we looked at the cheapest silver plan in each geographical market, to give a sense of the best price an insurance shopper could get. Since last year, the price of the cheapest silver plans has barely risen; it's actually going down in seven states. The average increase was just 1 percent. That's pretty remarkable considering that health insurance premiums nearly always go up. If you're the kind of customer who cares only about premiums, it pays in almost every market to go back to the marketplace this year and switch to the cheapest plan.
If you stayed with the cheapest silver plan from 2014 -- according to the Department of Health and Human Services, it was the most popular choice around the country -- those prices are going up almost everywhere. In some cases, they have increased by more than 10 percent. The average increase is 8.4 percent.
Here is an example of how those changes are playing out: In New York City, the cheapest 2014 silver plan was offered by MetroPlus and cost $359 a month, before tax credits, for a 40-year-old single nonsmoker. Renew that plan and the premium will increase by 17.3 percent. But switch to the cheapest plan now listed, offered by Health Republic, and the premium will go up by only 1 percent. The Health Republic network is broad, and includes providers who were in the MetroPlus plan. But consumers in other markets may need to be willing to jettison providers if they want the best price.
The third number we examined is important, too. For people with incomes between 138 percent and 400 percent of the federal poverty level -- about $33,000 to $95,000 for a family of three -- the federal government will kick in money to help pay for the insurance. Those subsidies are calculated based on the cost of the second-cheapest silver plan and the purchaser's income. What's happening in these plans can tell us how much the federal government's bill for subsidizing health insurance is going to go up. On average, the prices for the second-cheapest plans, called ''benchmark plans,'' are actually going down by 1.4 percent, and in most places where they are increasing, they are increasing modestly. That's good news for the federal budget.
The small increases in the cheapest silver plan and the decreases in benchmark plans are a sign the marketplace is working as intended, said Jonathan Gruber, an M.I.T. economist who helped design the marketplace structure in the Affordable Care Act. ''The main feature was that competition would bring rates down, and it did,'' he said.
A few important caveats about this data: We still don't know the rates in every state. The McKinsey database includes rates the company has collected from the 18 states and the District of Columbia, which have publicly posted the prices that insurers plan to charge consumers. About 43 percent of Americans eligible to sign up live in those states, which include New York, California, Michigan and Ohio. In many of the states included in this analysis, the rates are still being reviewed by regulators. Even in states where regulators have approved the rates, prices could go down before the marketplaces open on Nov. 15. As more state data becomes available, we plan to update our map.
But to keep premiums from rising, consumers will have to fight inertia. The Obama administration is trying to make it as easy as possible for people to preserve their coverage next year by simply renewing their current health plans. People who don't choose to shop again on Healthcare.gov will be automatically renewed in the plans they bought in 2014. That's not true for every state. Some states running their own marketplaces, including Colorado and Rhode Island, are either requiring consumers to log in and update their information before they can renew or recalculating tax credits before sending renewal notices. But the federal rule applies in a majority of states.
Historical evidence suggests that few customers will return to the marketplace to shop for a new health plan. Customers in the Affordable Care Act marketplace may be more price-sensitive than those in previous government insurance markets. But in those other plans, inertia has tended to set in.
Fewer than 10 percent of seniors change their Medicare Part D drug plans each year, and only 12 percent of federal employees switch plans on the federal benefit exchange. Studies have shown that, in the Medicare Part D market in particular, many more seniors would be better off if they changed plans more frequently.
In the marketplaces, it's not yet clear why rates on the most popular plans are increasing so much more than their competitors. It's possible insurers are charging more for these plans to take advantage of inertia and increase profits. It's also possible that some priced their initial policies unsustainably low, given the new nature of this market, and are now correcting.
Brendan Buck, a spokesman for America's Health Insurance Plans, an industry group, said the main factor driving premium increases was ''who signed up.'' Many of the new lowest cost plans are new market entrants, according to McKinsey, which means they may have less data on how expensive these new customers will be to cover. We're likely to get more insight into the forces driving premiums changes in coming years.
Automatically renewing marketplace plans will be a mistake for many people, but it is an especially risky one for the 85 percent of people who qualified for some sort of subsidy. The Obama administration has chosen not to recalculate the value of tax credits for people who don't return to the Healthcare.gov site.
If your subsidy should go down -- either because you have received a raise since last year or because the benchmark plan in the market became cheaper -- you could end up owing the government a lot more money than you think, and you won't find out until tax time. Sam Baker at National Journal has a good article walking through the mechanics of how this works.
Not everyone has to worry about these invisible price changes, especially if incomes haven't changed. But in markets where federal rules apply and the benchmark is going down a lot, it pays to return to the marketplace before renewing. Places where that will be an issue include parts of Georgia, Indiana and Ohio -- where benchmark prices are declining by more than 15 percent. For people in those areas, returning to the marketplace could prevent a surprise tax bill.
''The structure makes for a very competitive environment among the insurance carriers,'' said Paul Houchens, an actuary at Milliman, who estimates that, in some cases, what looks like a 5 percent premium rise could actually mean an increase of more than 30 percent. ''But,'' he said, ''I can see how it would create more confusion for consumers.''
The Upshot provides news, analysis and graphics about politics, policy and everyday life. nytimes.com/upshot
URL: http://www.nytimes.com/2014/09/18/upshot/with-new-health-law-shopping-around-can-be-crucial.html
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GRAPHIC: PHOTO: Mercy Cabrera, left, an insurance agent in Hialeah, Fla., helped Amparo Gonzalez buy insurance through the Affordable Care Act last year. Many health insurance premiums are increasing, but others are being cut. (PHOTOGRAPH BY JOE RAEDLE/GETTY IMAGES)
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The New York Times
January 20, 2016 Wednesday
Late Edition - Final
U.S. Toughens Rules for Latecomers Trying to Enroll Under Health Act
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 658 words
The Obama administration, responding to complaints from insurance companies, announced several steps on Tuesday that will make it harder for consumers to obtain health insurance after the annual open enrollment period.
Insurers say many consumers have belatedly signed up for coverage under the Affordable Care Act when they become sick and need care. Those latecomers drive up costs for people who sign up during the regular open enrollment period, insurers say. Open enrollment ends this year on Jan. 31.
The administration, which had created more than 30 ''special enrollment'' periods, sent emails to millions of Americans last year urging them to see if they might be eligible to sign up after the annual open enrollment deadline. But, insurers and state officials said, the federal government did little to verify whether late arrivals were eligible.
Kevin J. Counihan, the chief executive of the federal insurance marketplace, said Tuesday that special enrollment periods ''are not allowed for people who choose to remain uninsured and then decide they need health insurance when they get sick.''
Mr. Counihan said the administration would eliminate six of the special enrollment periods, including two for certain lawfully present noncitizens who experienced ''system errors'' and ''processing delays'' when they used HealthCare.gov. In addition, he said the government would clarify eligibility standards and step up enforcement to prevent abuse of special enrollment periods.
The actions appeared to have several purposes: to motivate consumers to sign up by the Jan. 31 deadline; to prevent an influx of large numbers of sick people into the market in the middle of the year; to persuade insurers to enter or stay in the public insurance marketplace; and to minimize rate increases in 2017 and later years.
Federal officials said nearly 950,000 people used special enrollment periods to get coverage through HealthCare.gov from late February to the end of June 2015. In some cases, insurers said, consumers dropped coverage soon after receiving costly medical services.
The marketplace must be attractive not only to consumers, but also to insurers, Mr. Counihan said. ''Building an attractive marketplace starts with establishing a predictable, stable set of rules that help to keep the risk pool balanced,'' he said, referring to the mix of healthy and unhealthy customers.
Most of the special enrollment periods will still be available, for example, when people marry, have a baby, lose job-based coverage or become ineligible for coverage under a parent's health plan at the age of 26.
People will still be eligible for late enrollment when they permanently move to a new address outside the coverage area of their health plan. But the administration said Tuesday that ''this special enrollment period cannot be used for a short-term or temporary move where the consumer doesn't plan to stay in their new location.'' And consumers would not qualify just because they were admitted to a hospital in another state.
Clare Krusing, a spokeswoman for America's Health Insurance Plans, a trade group, welcomed the administration's steps but said they did not go far enough. ''While this is an important first step,'' she said, ''more needs to be done to validate special enrollment requests.''
Insurers had, for example, urged the administration to narrow the ''exceptional circumstances'' in which the federal government could grant a special enrollment period.
In a blog post on Tuesday, Mr. Counihan said, ''Our program integrity team will pull samples of consumer records nationally and may request additional information from some consumers or take other steps to validate that consumers properly qualified for these special enrollment periods.''
In addition, he said, officials will emphasize to consumers that ''they may be subject to penalties under federal law if they intentionally provide false or untrue information.''
URL: http://www.nytimes.com/2016/01/20/us/us-toughens-rules-for-latecomers-trying-to-enroll-in-health-care-act.html
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February 7, 2014 Friday
A Hotelier Corrects His Testimony on the Impact of the Affordable Care Act
SECTION: BUSINESS; smallbusiness
LENGTH: 1116 words
HIGHLIGHT: In his initial testimony, Peter Anastos said that his company would make sure that its new hires worked fewer than 30 hours a week so that they would not qualify for health insurance.
Last week, The Agenda reported on a House committee hearing that examined a provision in the Affordable Care Act that requires companies with at least 50 employees to offer health insurance to any employee who works at least 30 hours a week. It appeared that a bill to raise that threshold to 40 hours, the Save American Workers Act, could be on a fast track to debate by the full House, and on Tuesday the legislation took a big step forward when it passed out of the Ways and Means Committee.
The bill's sponsor, Todd Young, an Indiana Republican, called his proposal an effort to protect workers who could see their hours reduced below the 30-hour threshold as companies seek to avoid the mandate to provide health insurance. "The new class of employees dubbed the 'Obamacare 29ers' continues to grow," Mr. Young said before the Save American Workers Act passed the committee, on a party-line vote. "The closer we get to Jan. 1, 2015, the more I suspect we'll continue to see the ranks of 29ers grow."
While the committee was considering the bill, however, its star witness from last week's hearing was correcting the record.
At the hearing, Peter Anastos, who owns the Maine Course Hospitality Group, appeared to firm up the convictions of the Republicans on the panel as he repeatedly insisted that he was going to make sure new hires, especially at three new hotels he was building, did not work 30 or more hours a week. Current employees who worked less than 30 hours a week, he said, would not be able to pick up extra shifts.
But in an email on Tuesday, Mr. Anastos said his company, which owns and operates a dozen hotels in New England, would not adopt this policy. "We have decided to hire the same way we always have and manage hours similarly as we have in the past," he wrote. "Yes, we will be much more conscious of when someone crosses that threshold, but we are going to try and remain as consistent as we can with our other properties, if affordable."
Mr. Anastos's status as a symbol of the hardships caused by the employer mandate was complicated from the outset, because his company already offers insurance to employees who work more than 30 hours a week, and has done so for years. Mr. Anastos said that his mistaken testimony arose out of a misunderstanding with the company's chief executive, Sean Riley. "It was my feeling that this" - managing employees to stay below 30 hours - "is the way we want to go," Mr. Anastos said in a subsequent conversation. "But he wants to do it the other way." Mr. Anastos also said that he believed that Mr. Riley and other managers agreed with his initial impulse, but then became convinced that such strategies were unnecessary. "And I agree with them," he said.
Last year, Mr. Anastos said, the expense of insuring the 67 employees who accepted the company's offer for health coverage came to $207,000. This year, the same insurance for the same employees will cost $268,000, an increase of nearly 30 percent. Next year, he said, if all 152 employees who now average more than 30 hours a week of work take up the company offer, those costs could rise to nearly $600,000.
Of course, it is possible that many of those employees will find insurance elsewhere and not take it from the company. But Mr. Anastos said that business has lately been profitable enough that he and his management team believe they may be able to cover those extra costs, as well as the costs for new employees at the new hotels.
In the interview, Mr. Anastos also said that the cost of covering more workers would not deter him from making new investments, despite an implication to the contrary in his testimony. "I'm concerned about the cost of health care," he said, "but at a downtown Marriott, it's not going to make a difference."
He also conceded that if Mr. Young's bill became law, and the threshold moved to 40 hours, his company would not change its business practices. Under Mr. Young's proposal, companies with at least 50 workers would face a penalty only if they failed to offer health insurance to employees who work 40 hours a week or more. (Employees with relatively low income who are not offered insurance could then receive subsidies to buy that insurance on government-run exchanges.) But Mr. Anastos said Maine Course would still offer insurance to employees who work more than 30 hours. If the new costs prove too high, or the economy turns, Mr. Anastos said, the company would reconsider.
Still, in the interview and in several subsequent emails, Mr. Anastos insisted that even if the current 30-hour requirement is not a direct threat to his business, it is at least an indirect threat - one that puts millions of hourly workers in peril. More marginal businesses that cannot afford to cover their employees, he said, including his competitors, will simply slash hours to avoid the mandate. "If I'm running the Marriott Courtyard, and the Hampton Inn across the street says that they're going to manage down to 30, then what?" he asked. "I'm going to be up against so many people who don't do it, because it's such a huge incentive."
The employer mandate was supposed to take effect this year. But last June, the Obama administration postponed carrying it out until 2015 to give the Internal Revenue Service time to finish writing the rules. Mr. Anastos testified at the House hearing on behalf of the International Franchise Association, a trade group that says 31 percent of franchisees have already reduced workers' hours in anticipation of the mandate and 27 percent have replaced full-time staff with part-timers.
A spokesman for the group, Matt Haller, declined to comment on Mr. Anastos's testimony, but said that the organization still supported the House legislation. Nor did the House committee itself retreat. "We applaud every business owner that can continue offering health insurance," said Sarah Swinehart, a spokeswoman for the House Ways and Means Committee. "They, and their workers, are the lucky ones. Obamacare is hurting job creation, cutting hours and leading to less take-home pay."
After the phone conversation in which Mr. Anastos corrected his testimony, he called back to press his case in favor of the legislation. He sounded subdued. He said he had heard from the franchise association, which evidently was not happy he had revised his account: "I basically got a phone call telling me to shut up."
An Employer Tells Congress the Health Care Mandate Could Triple His Costs
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
Should a Bakery With More Than 50 Employees Offer Health Insurance?
The Information We Still Need to Manage Our Health Care
Small Businesses Showing Little Interest in State SHOP Exchanges
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March 7, 2016 Monday
Late Edition - Final
Size of Health Care Networks Is to Become More Transparent Next Year
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 9
LENGTH: 946 words
WASHINGTON -- The Obama administration, responding to consumer complaints, says it will begin rating health insurance plans based on how many doctors and hospitals they include in their networks.
At the same time, the maximum out-of-pocket costs for consumers under the Affordable Care Act will increase next year to $7,150 for an individual and $14,300 for a family, the administration said. Consumer advocates said those costs could be a significant burden for middle-income people who need a substantial amount of care.
Under new rules to be published Tuesday in the Federal Register, insurers will still be allowed to sell health plans with narrow networks of providers. But consumers will know in advance what they are getting because the government will attach a label indicating the breadth of the network for each plan sold on HealthCare.gov.
About 12.7 million people signed up or had their coverage automatically renewed in the third annual open enrollment season, which ended on Jan. 31.
Many health plans offered in the public marketplaces provide a limited choice of doctors and hospitals, and some insurers narrowed their networks this year by excluding some doctors and dropping popular teaching hospitals.
Consumers have grumbled about the changes, and some say they have had difficulty finding medical specialists. But cost-conscious consumers have gravitated to these plans because they tend to offer lower premiums than health plans providing a greater choice of doctors and hospitals.
Consumers can already find out which health plans include a specific doctor. But until now they had no reliable way to determine if a health plan had a large or small network of providers. The new ratings will indicate how the breadth of a health plan's network compares with that of other plans in the same geographic area.
''This could be really helpful for a lot of consumers,'' said Sabrina Corlette, a consumer advocate and professor at the Health Policy Institute of Georgetown University.
Consumers have also complained about the out-of-pocket costs for many health plans under the Affordable Care Act.
''For many people, $7,000 of costs can be a huge impediment to actually receiving care,'' especially if patients incur those costs in a month or two at the start of a year, said Marc M. Boutin, the chief executive of the National Health Council, a coalition of advocacy groups for people with chronic diseases.
Out-of-pocket costs, as defined by the government, include deductibles and co-payments, but not the premiums that people pay for insurance. Each insurer sets limits on out-of-pocket costs for its health plans, and the limit cannot be higher than the maximum specified by the government. The maximum for an individual will exceed $7,000 next year for the first time. It will go up by $300 in 2017, after an increase of $250 this year.
Consumer groups say this rate of increase is unsustainable. Moreover, they say, high out-of-pocket costs have deterred some people with insurance from using expensive prescription drugs.
Ben Wakana, a spokesman for the Department of Health and Human Services, said that in setting the new ceiling on out-of-pocket costs, the administration had used a formula laid out in the Affordable Care Act. Before the law was adopted, he said, people with cancer or other serious illnesses could be bankrupted by hundreds of thousands of dollars in medical bills, and the law provides new protections.
People with low incomes can obtain discounts that reduce their deductibles and other out-of-pocket costs if they choose midlevel silver plans. Slightly more than half of the people with marketplace coverage received such ''cost-sharing reductions'' last year.
Ms. Corlette, the Georgetown University professor, said that in writing the new rules, ''the administration was walking a very delicate line, pushing forward with consumer protections while trying to keep insurers onboard and participating in the marketplaces.''
In some markets, consumers can choose from dozens of health plans. In a move intended to simplify the shopping experience, the Obama administration has devised six model health plans that it describes as standardized options. Federal officials specify the amount of deductibles, co-payments and other charges for doctors' services, hospital care, X-rays, laboratory tests and prescription drugs.
The standard features will make it easier for consumers to compare plans, officials said, and the government will highlight these plans in some way on HealthCare.gov. But the government is not requiring insurers to offer the standardized options or limiting their ability to offer other plans in 2017.
Another new requirement is meant to guarantee ''continuity of care'' for certain patients. If a health plan drops a doctor from its network without cause, the insurer must allow patients in ''an active course of treatment'' to continue seeing the doctor for up to 90 days. This protection would apply, for example, to patients receiving chemotherapy or radiation therapy for cancer and to women in the second or third trimester of pregnancy.
Under the new rules, consumers using the federal marketplace will be able to get help year-round from insurance counselors financed by the government. The counselors, known as navigators, help people sign up in the annual open enrollment period. The administration is expanding their duties to include teaching people how to use insurance, appeal denials of coverage and obtain exemptions.
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URL: http://www.nytimes.com/2016/03/07/us/health-law-insurance-plans-to-be-rated-by-network-size.html
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February 18, 2014 Tuesday
Late Edition - Final
Health Law and Antitrust
SECTION: Section A; Column 0; Editorial Desk; LETTER; Pg. 22
LENGTH: 248 words
To the Editor:
Re ''Health Law Goals Face Antitrust Hurdles,'' by Eduardo Porter (Economic Scene column, Feb. 5):
Enforcing the United States antitrust laws will not conflict with the goals of the Affordable Care Act. The goal of the antitrust laws is entirely consistent with the health law's objective to foster new and innovative forms of health care delivery.
The United States has a market-based health care system, and the success of the Affordable Care Act depends on those markets. If health care markets don't function, consumers are stuck with higher costs, lower quality and worse service.
The Federal Trade Commission is committed to protecting American consumers from any anticompetitive arrangements among providers. But we do not stand in the way of providers' finding new ways of coordinating and improving care.
The F.T.C. has challenged only a handful of the hundreds of mergers, acquisitions and new arrangements in the health care industry over the last few years. Moreover, there are many ways for providers to effectively coordinate care that do not require merger or acquisition or cause competitive concerns.
Antitrust is a critical ingredient for a well-functioning health system and achieving the goals of the health law. By safeguarding the functioning of health care markets, the Federal Trade Commission is allowing health reform to work and benefiting American consumers.
MARTIN GAYNOR Director, Bureau of Economics Federal Trade Commission Washington, Feb. 11, 2014
URL: http://www.nytimes.com/2014/02/18/opinion/health-law-and-antitrust.html
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September 25, 2012 Tuesday
Why the Health Care Tax Credit Eludes Many Small Businesses
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1247 words
HIGHLIGHT: The G.A.O. concluded that the credit was too small to sway business owners. Moreover, it said, claiming the credit is a task so complicated as to discourage many companies from trying.
The Agenda has now profiled three small businesses that are struggling in different ways with providing health insurance to employees. The companies are very different -- they trade in very different parts of the economy, and couldn't be located much further apart geographically -- but they do have one thing in common: Though all three have fewer than 25 employees, not one has qualified for the tax credit in the Affordable Care Act that was intended to help small businesses pay for health insurance. Indeed, the credit is one element of the controversial health law that has already fallen short of expectations.
Estimates of the number of businesses eligible to take the tax credit have ranged from 1.4 million to 4 million companies, but in May, the Government Accountability Office reported that only 170,300 firms actually claimed the credit in 2010. Of these, only a small fraction, 17 percent, were able to claim the whole credit.
For eligible companies, the credit effectively refunds 35 percent of health insurance expenses between 2010 and 2013.* After 2014, the credit increases to 50 percent and is available for any two consecutive years. The credit is fully available to companies with 10 or fewer full-time employees and average wages below $25,000. It phases out as the number of employees rises to 25 and wages grow to $50,000. In 2009, there were about 4.6 million companies with fewer than 10 employees, according to the Census Bureau, and 5.7 million with fewer than 100.
The credit was aimed squarely at the smallest companies, which rarely offer health insurance to employees. However, as we reported two weeks ago, it appears not to have persuaded very many to start offering insurance. The most recent study of employer health insurance from the Kaiser Family Foundation found that just half of all companies with fewer than 10 employees offered insurance, a share that has not moved much since 2005.
So why has the credit fallen short of expectations? The G.A.O. concluded that the credit was too small to sway business owners. Moreover, it said, claiming the credit is a task so complicated as to discourage many companies from trying. Companies have to determine the number of hours each employee worked in the year, as well as compile information about their insurance premiums. "Small-business owners generally do not want to spend the time or money to gather the necessary information to calculate the credit, given that the credit will likely be insubstantial," the report said, citing conversations with tax preparers. "Tax preparers told us it could take their clients from two to eight hours or possibly longer to gather the necessary information to calculate the credit and that the tax preparers spent, in general, three to five hours calculating the credit."
The G.A.O. report hints at the complexity with this delicious example:
On its Web site, I.R.S. tried to reduce the burden on taxpayers by offering "3 Simple Steps" as a screening tool to help taxpayers determine whether they might be eligible for the credit. However, to calculate the actual dollars that can be claimed, the three steps become 15 calculations, 11 of which are based on seven worksheets, some of which request multiple columns of information.
It may be tempting to hold the Internal Revenue Service responsible for whatever burden accompanies the tax credit, but in this case, the complexity is written directly into the law. It turns out that legislators wrote the provision in a way that makes it appear more generous than it really is. Many businesses with both fewer than 25 employees and average wages below $50,000 are in fact unable to claim the credit.
Under the law, once such a business has calculated its potential credit, it is required to reduce the credit first to account for any excess employees over 10 and then separately reduce the potential credit to account for any excess average wages paid over $25,000. For many companies, the two reductions exceed the potential credit itself - meaning the business gets no credit.
That's what happened to Carrie Van Dyck, who along with her husband owns the Herbfarm Restaurant outside of Seattle. Excluding its owners, the Herbfarm, which we profiled in June, employed the equivalent of about 21 or 22 full-time staff members, who were paid an average wage of about $35,000 - a few thousand dollars over the credit's threshold for 21 employees. The result surprised Ms. Van Dyck, she said recently by e-mail, because "it would seem that we are a pretty typical small, mom-and-pop type business that this should apply to."
Of course, by making the credit less generous, the senators who wrote the law made it less expensive to the United States Treasury. Now it is apparent that credit will be even cheaper than planned: initially it was expected to cost the Treasury $2 billion in 2010; instead it cost the government only a quarter of that.
The law also excludes owners and owners' families from counting toward the credit, which can cut both ways. On the one hand, owners don't count as employees and their salaries are excluded from the annual wages, exclusions that could make some companies eligible for a bigger credit than they might otherwise have gotten. On the other hand, premiums paid for the owners' and their families' insurance aren't eligible for the credit, which for some companies, as You're The Boss commenter JAB recently noted, "greatly reduces the incentive to provide coverage for employees."
The White House has said that the number of businesses claiming the credit for 2011 has grown to at least 360,000, but that is still well below even the smallest estimate of eligible businesses. Some advocates for the law say that more businesses will take advantage of the credit in 2014, when it grows to 50 percent, especially if the new insurance exchanges make it easier and cheaper for small companies to offer insurance.
The Obama administration has proposed making more businesses eligible for the credit, in part by starting phase-outs at higher thresholds, and also by changing the way it is calculated so that every business within the limits, such as the Herbfarm Restaurant, can take some amount of credit.
But judging from the comments of Representative Sam Graves, chairman of the House Small Business Committee, the initiative is unlikely to pass a Republican-controlled House anytime soon. "This tax credit has already largely failed to attract small-business owners, and expanding it will not make the president's health care law affordable," the Missouri Republican said in a statement. "For small employers that do not offer health insurance, tax incentives are unlikely to cause many of them to choose a massive new expense they just cannot afford in the first place." It was Mr. Graves who sought the G.A.O. report.
Of course, a business denied a credit has not been made worse off by the 2010 health law. But the law surely has raised and dashed a lot of hopes, and these are the early days - the sweeping changes that are the law's hallmark don't come until 2014.
*There are, of course, many caveats here, but the main one is that the company has to pay at least half of the premium.
A Small Restaurant Gets a Big Increase in Health Premiums - and Misses the Tax Credit
Small Business Health Insurance: Costs Still Going Up
How Small Businesses Are Coping With Health Insurance
Looking to the Affordable Care Act For Help
A Business Owner Expects the Worst From Health Insurance Overhaul
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March 10, 2017 Friday
Late Edition - Final
If 'Looking for Accuracy,' C.B.O. Is Fine Place to Start
BYLINE: By LINDA QIU
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 1018 words
WASHINGTON -- President Trump's spokesman on Wednesday deflected concerns that a bill to repeal the Affordable Care Act had yet to be scored by the nonpartisan Congressional Budget Office by questioning the agency's track record.
''If you're looking at the C.B.O. for accuracy, you're looking in the wrong place,'' Sean Spicer, the White House press secretary, said. ''I mean, they were way, way off the last time in every aspect of how they scored and projected Obamacare.''
''If you look at the number of people that they projected that would be on Obamacare, they are off by millions,'' he added. ''But, the idea that that is any kind of authority based on the track record that occurred last time is a little far-fetched.''
Mr. Spicer has a point that the C.B.O.'s projections for how many people would gain insurance under the health law were ''off by millions.'' But imprecision in Affordable Care Act projections does not give an accurate impression of the C.B.O.'s overall track record.
C.B.O.'s predictions were off, but less so than others'
The agency, created in 1974, released its analysis of the completed version of the health care law in March 2010. It estimated 21 million people would be enrolled in public marketplaces by 2016. The year ended with 11.5 million enrollees.
But according to a 2015 report from the Commonwealth Fund, a health care research group, the C.B.O.'s projections for the Affordable Care Act were more in line with what actually happened than four other prominent analyses from 2010.
''Nobody always gets this stuff right,'' said Sherry Glied, a health policy expert and the primary author of the report. ''But if you believe it's possible to make an assessment, they're the best at that.''
The C.B.O. also updates its figures to reflect new policies and economic conditions. The number of employers dropping coverage and pushing employees to public exchanges was far fewer than the C.B.O. anticipated, leading the agency to reduce its enrollment estimate from 21 million to 13 million in January 2016.
Overall, C.B.O. forecasts have been more accurate
Forecasts are difficult, but outside of the health care law, the C.B.O.'s projections have landed closer to reality.
For example, the C.B.O. estimated that the American Recovery and Reinvestment Act would cost $106 billion at the end of fiscal year 2009, 1 percent lower than the actual cost of $108 billion. And its prediction for the recovery act's impact on the federal deficit, an increase of $4.7 billion by the end of the 2015 fiscal year, was also near the actual impact of $5 billion.
In the C.B.O.'s assessment of its own accuracy, the agency says it has overestimated revenue by an average of 1.1 percent for two-year projections and by 5.3 percent for six-year projections since 1982.
Similarly, the C.B.O. concluded that its economic forecasts of the past four decades ''have been comparable in quality to those of the administration and the Blue Chip consensus,'' which aggregates analyses from the private sector.
Independent analysis of the C.B.O.'s forecasting tends to be even more generous, concluding it is not biased (though perhaps optimistic) and citing the agency as the most accurate of federal analysts.
Delighting, and frustrating, both left and right
Complaining about the referee is not a new tactic, and while the C.B.O. is certainly no stranger to criticism, it has retained a reputation for objectivity.
''All projections about the future are wrong. To me, the question isn't about accuracy, it's about bias. The C.B.O.'s role is to try to offer unbiased estimates,'' said Philip Joyce, a professor of public policy at the University of Maryland and the author of ''The Congressional Budget Office: Honest Numbers, Power, and Policymaking.''
After all, Mr. Joyce said, the C.B.O.'s past imprecision does not mean that its projections of the Obamacare repeal bill will be less accurate than analysis from the administration or its supporters.
Before the C.B.O. existed, estimates of the impact of legislation came from those trying to sell it, but the agency's creation has instilled a culture of fairness in government forecasting. When political appointees attempt to sway the Office of Management and Budget toward more favorable analyses, career officials would hold up the C.B.O. as a deterrent, according to Mr. Joyce.
Of course, that has not stopped politicians from impugning the agency when it produces an unfavorable projection. When the C.B.O. questioned the Reagan administration's analysis of its tax cuts, President Ronald Reagan hit back, calling the agency's numbers ''phony.'' On the other side, Republicans seized upon the C.B.O. analysis of President Clinton's health care plan that led to its ultimate demise in Congress.
''It's a bipartisan wet blanket,'' Ms. Glied said.
Mr. Spicer himself has cited the C.B.O. throughout the years, sometimes characterizing it as a neutral arbiter.
Bill gutting #ObamaCare would save half-trillion over a decade, CBO finds@thehill https://t.co/X8q21nsfqd -- Sean Spicer (@seanspicer) January 5, 2016
New RNC Ads Use CBO #Obamacare Report To Target @MaryLandrieu , Other Senate Dems http://t.co/8orqEqeOSM -- Sean Spicer (@seanspicer) February 12, 2014
Dem appointed head of CBO says he has not seen WH plan on sequester WATCH: http://t.co/2TlL33YW -- Sean Spicer (@seanspicer) February 12, 2013
What is unusual about Mr. Spicer's criticism, said Mr. Joyce, is that it came before the C.B.O. had wrapped up its analysis. The pre-emptive strike suggests the administration does not anticipate a rosy forecast.
For a president who has cast doubt on the official unemployment numbers and claims without evidence that his predecessor spied on him, this is perhaps particularly concerning.
''We desperately need neutral truth-tellers and fair scorekeepers. C.B.O. is one that we have,'' said Maya MacGuineas, president of the Committee for a Responsible Federal Budget. ''People shouldn't mess with C.B.O.''
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URL: http://www.nytimes.com/2017/03/09/us/politics/congressional-budget-office-sean-spicer.html
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March 9, 2017 Thursday
Late Edition - Final
The G.O.P. Unveils Its Health Care Plan
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 26
LENGTH: 766 words
To the Editor:
''G.O.P. Health Bill Trades Mandate for Tax Credits'' (front page, March 7) correctly points out real problems in Obamacare Lite. But the split in congressional support and in the latest polls indicates that we just might have a revision that will eventually fly with some amendments. This could be a watershed moment in health care in America.
For the G.O.P, the bill adds free market features. The Democrats lose (perhaps just temporarily) the individual and employer mandate, but keep the most important features. The net result is that we're on the road to a national health care system with an unwelcome G.O.P. detour.
Now everyone can claim a victory of sorts, and that's a good thing in these fractious times. The likely rise in premiums as the buyer pool shrinks will bring future adjustments. But what cannot be stopped is the direction of health care in America.
ALLEN PRICE, MOSS BEACH, CALIF.
To the Editor:
An egregious giveaway to the insurance companies has been cleverly disguised -- in full sight -- in the Republicans' pathetic stand-in for a serious health plan. The language in question trumpets the end to the penalty that Americans must now pay if opting out of health coverage. As your article notes: ''People who let their insurance coverage lapse, however, would face a significant penalty. Insurers could increase their premiums by 30 percent.''
This little twist turns the Obamacare penalty -- which went to the government to help subsidize health coverage for all -- into a river of cash for (guess who?) the insurance companies. Bah.
GARY E. OSIUS, NEW YORK
To the Editor:
Re ''No Wonder They Hid the Health Care Bill'' (editorial, March 8):
Republicans have wasted seven years trying to repeal and replace Obamacare, and this latest effort is a cruel joke to the millions of Americans who depend on the Affordable Care Act. Millions of people will likely lose or drop their health care coverage, and millions on Medicaid will surely be affected negatively. The G.O.P. says health care will be cheaper and better because their bill will increase competition among insurance companies. But the simple truth is that the insurance industry is waiting with bated breath to have many millions of confused and desperate customers at their mercy.
And speaking of costs, the House Republicans are so eager to sneak this bill past the public that its costs have not even been analyzed by the Congressional Budget Office! What the nation needs is a Medicare-for-all system, run by and funded by people who truly understand health care delivery, and whose motives are quality, affordable patient care, not profit.
HENRY A. LOWENSTEIN, NEW YORK
The writer is a former chief executive for both for-profit and nonprofit health care companies.
To the Editor:
An important part of proposed Republican changes to the Affordable Care Act is the change in federal Medicaid funding to a system of block grants to the states. This will hurt Republican-leaning states more than Democratic-leaning states, as many of the reddest states are among those receiving the maximum match for their Medicaid programs from the federal government (about 70 percent) while many of the bluest states receive the lowest allowable match (50 percent).
States that have 70 percent, or close to 70 percent, of their Medicaid programs funded by the federal government include Alabama, Mississippi, Arkansas, North and South Carolina, and Georgia. States that ask the federal government to pay only 50 percent of their Medicaid costs include California, Washington, New York, New Jersey, Connecticut, Massachusetts and Maryland.
Red-state governors might be a bit less enthusiastic about ''repeal and replace'' when they realize that they have the most to lose.
JONATHAN ENGEL, NEW YORK
The writer is a professor of health care policy and management at the Marxe School of Public and International Affairs, Baruch College, CUNY.
To the Editor:
The Republican Party has just given the House of Representatives back to the Democrats. The G.O.P. health care proposal will reduce coverage so substantially for so many people that Democrats can regain control of the House in 2018 -- if they just give Republicans a little of their own medicine.
Republicans gave the Affordable Care Act a name -- Obamacare -- in a calculated strategy to undermine the law. Their scorched-earth effort to ''repeal and replace'' needs a moniker, too, one that holds them accountable. If the Democrats call it ''Republicare,'' voters will get the message loud and clear.
JONATHAN GIBSONSHREWSBURY, VT.
URL: http://www.nytimes.com/2017/03/08/opinion/the-republicans-unveil-their-health-care-plan.html
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The New York Times
December 5, 2015 Saturday
Late Edition - Final
Not Even Catharsis Is Seen in Senate Vote to Repeal Health Law
BYLINE: By DAVID M. HERSZENHORN
SECTION: Section A; Column 0; National Desk; NEWS ANALYSIS; Pg. 12
LENGTH: 1169 words
WASHINGTON -- Senate Republicans have finally fulfilled their long quest to pass legislation repealing President Obama's landmark health care law, and Congress will soon send the measure to the White House, where it might have a chance of being folded into origami or a fleet of paper airplanes, but no possibility of being signed into law.
While a veto is certain, putting the repeal measure on Mr. Obama's desk will fulfill a pledge by Republicans, highlighting how fiercely they still oppose the law nearly six years after it was passed solely by the votes of Democrats, the only bill of such consequence in modern American history to be approved on a strictly party-line vote.
So, what next?
It is unclear that lawmakers have drawn constructive lessons from the experience, and there is no sign that either party will use the repeal vote as a cathartic turning point onto a more cooperative path. Republicans say they will spend the election year using the vote as part of a broader call to elect a president of their party to get rid of the Affordable Care Act altogether. Democrats concede cooperation from their side is unlikely.
The vote on Thursday night was the first time since enactment of the health care law in March 2010 that the Senate was able to clear a repeal measure. And Republicans were able to do it only by using a special legislative vehicle called a budget reconciliation bill, which is not subject to a filibuster, and their vote, too, was strictly party line. (The House by contrast has voted at least 61 times on bills to repeal the law, or dismantle core components of it.)
For Representative Tom Price, Republican of Georgia, who is also an orthopedic surgeon and one of the toughest critics of the health care law, the Senate bill was such a momentous occasion that he walked across the Capitol to watch the proceedings.
''It's good stuff, good stuff,'' Mr. Price said. ''This is simply the majority in Congress, representing the American people.''
That same point was driven home earlier in the day by Speaker Paul D. Ryan of Wisconsin, who vowed to put forward alternatives to the health care law next year, mainly as an appeal to voters, neither seeking nor expecting any cooperation from Democrats.
''There are a lot of other ideas out there, but what all conservatives can agree on is this: We think government should encourage personal responsibility, not replace it,'' Mr. Ryan said. ''We think prices are going up because people have too few choices, not because they have too many. And we think this problem is so urgent that, next year, we are going to unveil a plan to replace every word of Obamacare.''
Democrats, too, said they had little hope of any change in the dynamic and expected to continue to have to beat back Republican efforts to gut the Affordable Care Act.
''I wish they would work with us, I really do,'' said Senator Bob Casey, Democrat of Pennsylvania, adding that he had no hope that would happen in an election year.
Veteran lawmakers in each party said that there was an underlying lesson about the crucial need for bipartisanship on major legislation -- even in an era of encrusted polarization. Not having a single Republican vote for the law, lawmakers said, made it politically difficult for Democrats to acknowledge the flaws that are inevitable with any major piece of legislation, and virtually impossible for them to seek Republican support to repair it.
''Surely one of the great lessons to learn here is you need to do whatever is necessary to get some people's views from the other side into what you are doing so that they buy into what you are doing,'' said Senator Roy Blunt, Republican of Missouri.
Democrats have long said that many Republican ideas were included in the health care law, particularly proposals drawn up in lengthy negotiations led by former Senator Max Baucus, Democrat of Montana, which included the participation of some Republican senators -- Charles E. Grassley of Iowa, Mike Enzi of Wyoming, and Olympia J. Snowe of Maine. None of the three ultimately voted for the bill.
Only a small minority of lawmakers, including Senator Susan Collins, Republican of Maine, who joined Democrats in voting against the repeal bill on Thursday night, have voiced any willingness to work constructively to improve the health care law.
Ms. Collins said that lawmakers needed to recognize that the law is now a fact of life for many Americans, particularly the more than 17 million people who have gained medical coverage paid for by tax subsidies or through Medicaid, and that some parts of the law were truly popular.
''I firmly believe that we have to replace it, with something, that repeal alone is not sufficient even though I oppose the law,'' Ms. Collins said. ''But it's now years later and unraveling it, completely unraveling it would be difficult if you don't have a plan to replace it. You have millions of people in this country who now are dependent on the subsidies that are in Obamacare or who are receiving help through Medicaid in those states that did adopt the expansion. And you have to recognize that that's a reality.''
Ms. Collins said she had been working on legislation with Senator Bill Cassidy, Republican of Louisiana and also a physician, on legislation that would fix some problems in the health care law and allow states to make changes, provided they develop alternative policy proposals.
Senator Lamar Alexander, Republican of Tennessee and chairman of the Health, Education Labor and Pensions Committee, said that he would advocate an incremental approach going forward.
''We've made our point about repeal,'' Mr. Alexander said, summing up how each side feels about the law. ''He's for it. We're against it. Now let's move on to what we are going to do next.''
Other Republicans said that while limited improvements might be possible, they viewed the health care law as too flawed to be fixed, and Mr. Obama as unwilling to entertain big changes.
''We actually are looking for things we can do on a bipartisan basis, but I think people don't hold out a lot of hope that Obamacare will be one of them,'' said Senator John Cornyn of Texas, the No. 2 Republican. ''It's just too identified with the president.''
Mr. Cornyn said adopting the repeal measure was important even knowing a veto was inevitable.
''We recognize that we are not going to be able to change the Affordable Care Act until we get a new president, but I think it was an important statement to make,'' he said.
Ms. Collins said she agreed the repeal bill would send an important message to Mr. Obama, even as she opposed another provision that would cut off financing of Planned Parenthood and potentially force the group to close clinics all across the country.
''Everyone will know we sent it to the president,'' Ms. Collins said. ''And maybe now we can move on.''
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URL: http://www.nytimes.com/2015/12/05/us/politics/not-even-catharsis-is-seen-in-senate-vote-to-repeal-health-law.html
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The New York Times
May 26, 2013 Sunday
Late Edition - Final
Obamacare's Other Surprise
BYLINE: By THOMAS L. FRIEDMAN
SECTION: Section SR; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 11
LENGTH: 905 words
LISTENING to the debate about President Obama's health care plan, some critics argue that Obamacare is going to need Obamacare -- because it's going to be a ''train wreck.'' Obama officials insist they're wrong. We'll just have to wait and see whether the Affordable Care Act, as the health care law is officially known, surprises us on the downside. But there is one area where the law already appears to be surprising on the upside. And that is the number of health care information start-ups it's spurring. This is a big deal.
The combination of Obamacare regulations, incentives in the recovery act for doctors and hospitals to shift to electronic records and the releasing of mountains of data held by the Department of Health and Human Services is creating a new marketplace and platform for innovation -- a health care Silicon Valley -- that has the potential to create better outcomes at lower costs by changing how health data are stored, shared and mined. It's a new industry.
Obamacare is based on the notion that a main reason we pay so much more than any other industrial nation for health care, without better results, is because the incentive structure in our system is wrong. Doctors and hospitals are paid primarily for procedures and tests, not health outcomes. The goal of the health care law is to flip this fee-for-services system (which some insurance companies are emulating) to one where the government pays doctors and hospitals to keep Medicare patients healthy and the services they do render are reimbursed more for their value than volume.
To do this, though, doctors and hospitals need instant access to data about patients -- diagnoses, medications, test results, procedures and potential gaps in care that need to be addressed. As long as this information was stuffed into manila folders in doctors' offices and hospitals, and not turned into electronic records, it was difficult to execute these kinds of analyses. That is changing. According to the Obama administration, thanks to incentives in the recovery act there has been nearly a tripling since 2008 of electronic records installed by office-based physicians, and a quadrupling by hospitals.
The Health and Human Services Department connected me with some start-ups and doctors who've benefited from all this, including Dr. Jen Brull, a family medicine specialist in Plainville, Kan., who said that she was certain she had been alerting her relevant patients to have colorectal cancer screening -- until she looked at the data in her new electronic health care system and discovered that only 43 percent of those who should be getting the screening had done so. She improved it to 90 percent by installing alerts in her electronic health records, and this led to the early detection of cancer in three patients -- and early surgery that saved these patients' lives and also substantial health care expense.
Todd Park, the White House's chief technology officer, said many new apps being developed have been further fueled by the decision by Health and Human Services to make available massive amounts data that it had gathered over the years but had largely not been accessible in computer readable forms that could be used to improve health care.
It started in March 2010 when Health and Human Services met with ''45 rather skeptical entrepreneurs,'' said Park, ''and rather meekly put an initial pile of H.H.S. data in front of them -- aggregate data on hospital quality, nursing home patient satisfaction and regional health care system performance. We asked the entrepreneurs what, if anything, they might be able to do with this data, if we made it supereasy to find, download and use.'' They were told that in 90 days the department would hold a ''Health Datapalooza,'' -- a public event to showcase innovators who harnessed the power of this data to improve health and care.
Ninety days later, entrepreneurs showed up and demonstrated more than 20 new or upgraded apps they had built that leveraged open data to do everything from helping patients find the best health care providers to enabling health care leaders to better understand patterns of health care system performance across communities, said Park. In 2012, another ''Health Datapalooza'' was held, and this time, he added, ''1,600 entrepreneurs and innovators packed into rooms at the Washington Convention Center, hearing presentations from about 100 companies who were selected from a field of over 230 companies who had applied to present.'' Most had been started in the last 24 months.
Among the start-ups I met with are Eviti, which uses technology to help cancer patients get the right combination of drugs or radiation from Day 1, which can lower costs and improve outcomes; Teladoc, which takes unused slices of doctors' time and makes use of it by connecting them with remote patients, reducing visits to emergency wards; Humedica, which helps health care providers analyze their electronic patient records, tracking what was done to a patient, and did they actually get better; and Lumeris, which does health care analytics that uses real-time data about every aspect of a patient's care, to improve medical decision-making, collaboration and cost-saving.
Obamacare will be a success only if it can deliver improved health care for more people at affordable prices. That remains to be seen. But at least it is already spurring the innovation necessary to make that happen.
URL: http://www.nytimes.com/2013/05/26/opinion/sunday/friedman-obamacares-other-surprise.html
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The New York Times
August 16, 2016 Tuesday
The New York Times on the Web
Aetna to Pull Back From Public Health Care Exchanges
BYLINE: By ROBERT PEAR
SECTION: Section ; Column 0; Washington; Pg.
LENGTH: 568 words
WASHINGTON -- In a blow to President Obama's health care law, Aetna, one of the nation's major insurers, said Monday that it would sharply reduce its participation in the law's public marketplaces next year.
Aetna said it would no longer offer individual insurance products on the exchanges in about two-thirds of the 778 counties where it now provides such coverage. The company will maintain a presence on exchanges in Delaware, Iowa, Nebraska and Virginia, it said.
In recent months, the large insurers UnitedHealth and Humana also said that they intended to pull back from the online exchanges, and other insurers are struggling to break even in marketplaces where low prices appear to be the top priority for low-income consumers.
The exchanges are a centerpiece of the Affordable Care Act: the only place where consumers can obtain subsidies to buy health insurance, which most Americans are required to have under the 2010 law. About 11 million consumers have coverage through the marketplaces, and about 85 percent of them receive subsidies in the form of tax credits.
Mark T. Bertolini, the chairman and chief executive of Aetna, said the company was responding to financial losses: ''a second-quarter pretax loss of $200 million and total pretax losses of more than $430 million since January 2014 in our individual products.''
''As a strong supporter of public exchanges as a means to meet the needs of the uninsured, we regret having to make this decision,'' Mr. Bertolini said. But, he added, the company cannot provide affordable, high-quality plans through the exchanges without a larger number of healthy people to help offset the costs of coverage for less healthy consumers.
''Individuals in need of high-cost care'' account for a disproportionate share of the enrollment in Aetna's marketplace plans, and the federal government does not adequately adjust its payments to account for these costs, he said.
Obama administration officials reacted angrily to Aetna's announcement. They suggested that Aetna was retaliating against the administration because the Justice Department filed suit last month to block Aetna's proposed acquisition of Humana. Attorney General Loretta E. Lynch said that transaction would reduce competition in violation of federal antitrust law.
Kevin J. Counihan, the chief executive of the federal insurance exchange, said the marketplace would remain strong and vibrant despite Aetna's decision.
''It's no surprise that companies are adapting at different rates to a market where they compete for business on cost and quality, rather than by denying coverage to people with pre-existing conditions,'' Mr. Counihan said Monday.
In a conference call with securities analysts in April, Mr. Bertolini said that Aetna had 911,000 members with individual coverage through the exchanges and added, ''We see this as a good investment.''
Senator Elizabeth Warren, Democrat of Massachusetts, said she saw a possible connection between the antitrust case against Aetna and its decision to reconsider participating in the exchanges.
''Aetna may not like the Justice Department's decision to challenge its merger, and it has every right to fight that decision in court,'' Ms. Warren said in a Facebook post last week. But, she said, ''the health of the American people should not be used as bargaining chips to force the government to bend to one giant company's will.''
URL: http://www.nytimes.com/2016/08/16/us/politics/aetna-health-care-law-marketplace.html
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The New York Times
March 3, 2017 Friday
Late Edition - Final
Paul Ryan Is Wrong on Freedom
BYLINE: By BRYCE COVERT.
Bryce Covert is the economic policy editor at ThinkProgress and a contributor to The Nation.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTOR; Pg. 27
LENGTH: 919 words
In his first address to Congress, President Trump made many sweeping pledges, but one of them was familiar to anyone who listened to him campaign. He said that he was ''calling on this Congress to repeal and replace Obamacare'' and demanding ''reforms that expand choice, increase access, lower costs and, at the same time, provide better health care.''
That's a lot to promise, and Republicans have thus far been unable to get on the same page about how to repeal the Affordable Care Act and what should take its place. But Mr. Trump is not the one who has to deliver on it. It falls to House Speaker Paul Ryan to rally the troops.
For his part, Mr. Ryan has been diligently tweeting pledges to the American people that the law is on its way out. Republicans haven't landed on a replacement plan yet. But Mr. Ryan is sure they will come up with something because they know, as he said in a recent tweet, ''Freedom is the ability to buy what you want to fit what you need.''
He went on to argue that Obamacare abridges this freedom by telling you what to buy. But his first thought offers a meaningful and powerful definition of freedom. Conservatives are typically proponents of negative liberty: the freedom from constraints and impediments. Mr. Ryan formulated a positive liberty: freedom derived from having what it takes to fulfill one's needs and therefore to direct one's own life.
In so doing, Mr. Ryan inadvertently revived an idea that desperately needs to be resuscitated -- the idea that freedom requires not just a lack of barriers, but also the conditions that allow people to live their lives fully. Deprivation, then, is a constraint on Americans' freedom.
This conception harks back to President Franklin D. Roosevelt's Four Freedoms. In his third term, Roosevelt delivered a State of the Union address that outlined four core principles, freedom from want among them. He later built on that idea and proposed a second Bill of Rights for every citizen. ''True individual freedom cannot exist without economic security and independence,'' he declared. '' 'Necessitous men are not free men.' ''
Among the rights he laid out were to a job and an education, to earn enough to buy the necessities, to live in a ''decent home,'' and to medical care and good health.
That last right, of course, is what Mr. Ryan was threatening in his tweet. The Affordable Care Act's extension of health care coverage, coupled with the individual mandate to buy it, has brought the uninsured rate to an all-time low. Some studies have found that this has had a positive impact on low-income Americans' health, freeing them from constant worrying about injury and illness.
It's also making them economically freer. Medical debt has long been one of the biggest drags on Americans' finances. But gaining health insurance through the A.C.A.'s Medicaid expansion, for example, saved enrollees money on their health care. They then used that money to pay down debts.
Separating health insurance from employment has also freed people to pursue the work they want to be doing. Health care expansions can decrease ''job lock,'' the phenomenon of people staying in jobs because they can't afford to strike out on their own and lose their insurance. Preliminary research indicates this may be happening for Americans who can fall back on the A.C.A. Nearly one and a half million self-employed people and small-business owners got coverage through its exchanges in 2014.
Republicans promise to replace the Affordable Care Act with something better, although they haven't agreed on what that will be. What they can say is that it will be teeming with freedom. With the exception of Mr. Ryan, theirs is a negative freedom: a drop in the insurance rate would be a positive sign of the ''personal liberty'' of not being subject to the individual mandate, for example. Their plan will be built on ''freedom and individual responsibility.'' A constraint would be lifted. Who cares if uninsured people suffer because they can't get medical care?
It's not just health insurance coverage, though, that ensures a person's freedom. It's difficult to pursue one's dreams on an empty stomach. How do you start a business without being able to afford rent?
That reality demands a more extensive agenda than government-expanded health insurance. It mandates that Americans be guaranteed enough food to eat, a safe and affordable place to live and a sufficient source of income.
All of this is in opposition to Mr. Ryan's ideas. He rose to prominence by releasing a series of budget blueprints that proposed slashing government spending by trillions of dollars. And in every single one, about two-thirds of those cuts are visited upon the things that already help people with limited means survive, such as food stamps, Pell Grants for education and programs that boost their incomes.
Even though Mr. Ryan says he believes that freedom is ''the ability to buy what you want to fit what you need,'' he doesn't want the government to do anything to help people experience that freedom. If he got his way on spending, the programs that allow the poor and struggling to buy food, housing and the other things they need would be utterly debilitated. The rich are the only ones who could be truly free in his vision of the country.
But he has reintroduced a potent definition of freedom. We need to reclaim it.
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URL: http://www.nytimes.com/2017/03/03/opinion/paul-ryans-misguided-sense-of-freedom.html
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The New York Times
March 26, 2014 Wednesday
Late Edition - Final
Democrats, as Part of Midterm Strategy, to Schedule Votes on Pocketbook Issues
BYLINE: By JEREMY W. PETERS and MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 920 words
WASHINGTON -- The White House and congressional Democrats are preparing to step up attacks on Republicans over pocketbook issues like the minimum wage in the most aggressive and coordinated move yet to try to reverse the Republican momentum that threatens their control of the Senate in the final two years of the Obama presidency.
The effort is set to begin within the next two weeks in the Senate when Democrats will call a vote on their proposal to increase the minimum wage to $10.10, and it will continue through spring and summer with additional legislation to eliminate the pay gap between men and women, lower interest rates on college loans and close tax loopholes that benefit corporations with business overseas.
The votes will be timed to coincide with campaign-style trips by President Obama, with the first planned around the time of the minimum-wage vote.
The proposals have little chance of passing. But Democrats concede that making new laws is not really the point. Rather, they are trying to force Republicans to vote against them.
''We think we need a sword and a shield,'' said Senator Charles E. Schumer of New York, the No. 3 Democrat who has been working with the White House on an approach to combine the bully pulpit of the presidency with a package of bills in Congress. ''I don't think we'll ever overcome the Republican attacks on Obamacare, but I think we can mute it greatly.''
Democrats remain on the defensive about the missteps with the rollout of the Affordable Care Act, problems that have only been amplified by a barrage of attack ads in battleground states like Alaska, Louisiana and North Carolina.
Republicans accused Mr. Obama and his fellow Democrats of trying to change the subject.
''These are poll-tested political messages that they want to put on the floor to get Republicans on the record voting against seniors and children and every other group you can think of,'' said Senator John Thune, Republican of South Dakota and the head of the Republicans' policy arm. ''It's noise.''
Where Democrats hope voters will see a Republican Party that favors the privileged at the expense of the middle class, Republicans want voters instead to see a Democratic Party that has put the country's prosperity at risk through government overreach and bad policy.
This is a version of the same fight that played out in 2012 when Mr. Obama won re-election and Democrats gained seats in both houses of Congress by portraying Mitt Romney and Republicans as callous and indifferent to the plight of working-class Americans. The biggest difference, of course, is that Republicans can now focus real-time problems of the health care law, an advantage that Democrats might find hard to surmount.
The name of the Democrats' plan, ''A Fair Shot for Everyone,'' even echoes a line Mr. Obama repeated often on the campaign trail.
''Ultimately, elections are about whose side you're on,'' said Senator Debbie Stabenow, Democrat of Michigan, who has been working with Mr. Schumer on the strategy.
The plan calls for bringing at least 10 different bills to a vote. In addition to the Minimum Wage Fairness Act and the Paycheck Fairness Act, others that are likely to be voted on include a Bring Jobs Home Act that would create tax credits for costs associated with bringing production back to the United States, an act to fund the nation's infrastructure repair needs and one to make it more difficult to pass laws that raise the Medicare eligibility age.
After disagreements over Syria, domestic surveillance and some high-profile White House nominees strained relations between the White House and congressional Democrats, they have been working more closely together with regular strategy sessions between senior aides in the West Wing and their counterparts in the House and Senate. Representatives from labor unions and liberal organizations like the Center for American Progress and United for Change have also attended.
Those sessions are scheduled to continue weekly for the rest of the year.
Privately, White House officials say they have no intention of searching for any grand bargain with Republicans on any of these issues. ''The point isn't to compromise,'' a senior White House official said, speaking anonymously to divulge strategy. ''We don't have a willing partner for compromise.''
Part of the goal is to energize the Democratic base, which will be crucial to turnout in the more conservative states where the party needs to win this year. But the message of fairness also has appeal to swing voters.
''I think this is helping re-establish a connection with what people care about, and that's whether the middle class is growing,'' said Senator Michael Bennet, Democrat of Colorado and the head of the Democratic Senatorial Campaign Committee. ''This ought to help us with Democratic voters, independent voters and Republican voters. Just look at the polling on the minimum wage.''
But so far, the numbers favor the Republicans, both in polling in the most competitive races and in gauges of voter intensity. This could be especially the case in states like Montana and Arkansas, where Republicans significantly outnumber Democrats and energized conservatives may make all the difference.
One question Republicans must contend with is whether their focus on attacking the Affordable Care Act is too narrow.
''People understand it's about more than health care,'' said Senator Roy Blunt, Republican of Missouri. ''It's about the unintended consequences of a government reaching further than it can grasp.''
URL: http://www.nytimes.com/2014/03/26/us/politics/democrats-as-part-of-midterm-strategy-to-schedule-votes-on-pocketbook-issues.html
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GRAPHIC: PHOTO: Senator Charles E. Schumer, shown with his Democratic colleague Richard J. Durbin, is working with the White House to combine the power of the presidency with a package of bills. (PHOTOGRAPH BY J. SCOTT APPLEWHITE/ASSOCIATED PRESS)
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The New York Times
November 15, 2015 Sunday
Late Edition - Final
Many Say High Deductibles Make Their Health Law Insurance All but Useless
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 22
LENGTH: 1258 words
WASHINGTON -- Obama administration officials, urging people to sign up for health insurance under the Affordable Care Act, have trumpeted the low premiums available on the law's new marketplaces.
But for many consumers, the sticker shock is coming not on the front end, when they purchase the plans, but on the back end when they get sick: sky-high deductibles that are leaving some newly insured feeling nearly as vulnerable as they were before they had coverage.
''The deductible, $3,000 a year, makes it impossible to actually go to the doctor,'' said David R. Reines, 60, of Jefferson Township, N.J., a former hardware salesman with chronic knee pain. ''We have insurance, but can't afford to use it.''
In many states, more than half the plans offered for sale through HealthCare.gov, the federal online marketplace, have a deductible of $3,000 or more, a New York Times review has found. Those deductibles are causing concern among Democrats -- and some Republican detractors of the health law, who once pushed high-deductible health plans in the belief that consumers would be more cost-conscious if they had more of a financial stake or skin in the game.
''We could not afford the deductible,'' said Kevin Fanning, 59, who lives in North Texas, near Wichita Falls. ''Basically I was paying for insurance I could not afford to use.''
He dropped his policy.
As the health care law enters its third annual open enrollment period, premiums and subsidies have been one of the administration's main selling points.
''Most Americans will find an option that costs less than $75 a month,'' President Obama said.
Sylvia Mathews Burwell, the secretary of health and human services, issued a report analyzing premiums in the 38 states that use HealthCare.gov. ''Eight out of 10 returning consumers will be able to buy a plan with premiums less than $100 a month after tax credits,'' she said.
But in interviews, a number of consumers made it clear that premiums were only one side of the affordability equation.
''Our deductible is so high, we practically pay for all of our medical expenses out of pocket,'' said Wendy Kaplan, 50, of Evanston, Ill. ''So our policy is really there for emergencies only, and basic wellness appointments.''
Her family of four pays premiums of $1,200 a month for coverage with an annual deductible of $12,700.
In Miami, the median deductible, according to HealthCare.gov, is $5,000. (Half of the plans are above the median, and half below it.) In Jackson, Miss., the comparable figure is $5,500. In Chicago, the median deductible is $3,400. In Phoenix, it is $4,000; in Houston and Des Moines, $3,000.
Ms. Burwell said the administration had ''seen high levels of satisfaction with the marketplace.''
And the marketplaces do vary. In Newark, some plans have no deductible, although the median deductible is $2,000, according to HealthCare.gov.
Health officials and insurance counselors cite several mitigating factors. All plans must cover preventive services like mammograms and colonoscopies without a deductible or co-payment. Some plans may help pay for some items, like generic drugs or visits to a primary care doctor, before patients have met the deductible. Under the Affordable Care Act, health plans must have an overall limit on out-of-pocket costs, to protect people with serious illness against financial ruin.
In addition, people with particularly low incomes can obtain discounts known as cost-sharing reductions, which lower their deductibles and other out-of-pocket costs if they choose midlevel silver plans. Consumer advocates say this assistance makes insurance a good bargain for people with annual incomes from 100 percent to 250 percent of the poverty level ($11,770 to $29,425 for an individual).
To those worried about high out-of-pocket costs, Dave Chandra, a policy analyst at the liberal-leaning Center on Budget and Policy Priorities, has some advice: ''Everyone should come back to the marketplace and shop. You may get a better deal.''
But for many consumers, the frustration is real, as is the financial strain. In employer-sponsored health plans, deductibles have also been rising as companies shift costs to workers. Still, the average annual deductible in employer plans, $1,320 for individual coverage according to the Kaiser Family Foundation, is considerably less than the deductibles in many marketplace plans.
The Internal Revenue Service defines a high-deductible health plan as one with an annual deductible of at least $1,300 for individual coverage or $2,600 for family coverage.
Sara Rosenbaum, a professor of health law and policy at George Washington University who supports the health law, said the rising deductibles were part of a trend that she described as the ''degradation of health insurance.''
Insurers, she said, ''designed plans with a hefty use of deductibles and cost-sharing in order to hold down premiums'' for low- and moderate-income consumers shopping in the public marketplaces.
But the deductibles are so high they may be scaring away some consumers.
Alexis C. Phillips, 29, of Houston, is the kind of consumer federal officials would like to enroll this fall. But after reviewing the available plans, she said, she concluded: ''The deductibles are ridiculously high. I will never be able to go over the deductible unless something catastrophic happened to me. I'm better off not purchasing that insurance and saving the money in case something bad happens.''
People who go without insurance next year may be subject to a penalty of $695 or about 2.5 percent of their household income, whichever is greater.
Karin Rosner, a 45-year-old commercial freelance writer who lives in the Bronx, pays about $300 a month, after a subsidy, for a silver insurance plan with a $1,750 deductible and a limit of $4,000 a year on out-of-pocket expenses.
She is extremely nearsighted and has an eye condition that puts her at risk for a detached retina, but has put off visits to a retina specialist because, she said, she would have to pay the entire cost out of pocket.
''While my premiums are affordable, the out-of-pocket expenses required to meet the deductible are not,'' said Ms. Rosner, who makes about $30,000 a year.
Mr. Fanning, the North Texan, said he and his wife had a policy with a monthly premium of about $500 and an annual deductible of about $10,000 after taking account of financial assistance. Their income is about $32,000 a year.
The Fannings dropped the policy in July after he had a one-night hospital stay and she had tests for kidney problems, and the bills started to roll in.
Josie Gibb of Albuquerque pays about $400 a month in premiums, after subsidies, for a silver-level insurance plan with a deductible of $6,000. ''The deductible,'' she said, ''is so high that I have to pay for everything all year -- visits with a gynecologist, a dermatologist, all blood work, all tests. It's really just a catastrophic policy.''
Another consumer, Anne Cornwell of Chattanooga, Tenn., said she was excited when Congress passed the Affordable Care Act because she had been uninsured for several years. She is glad that she and her husband now have insurance, because he has had tonsil cancer, heart problems and kidney stones this year.
But with a $10,000 deductible, it has still not been easy.
''When they said affordable, I thought they really meant affordable,'' she said.
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URL: http://www.nytimes.com/2015/11/15/us/politics/many-say-high-deductibles-make-their-health-law-insurance-all-but-useless.html
LOAD-DATE: November 15, 2015
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GRAPHIC: PHOTO: Bruno Celis showed health insurance options to Julio Mendez and his family in San Francisco. (PHOTOGRAPH BY JIM WILSON/THE NEW YORK TIMES)
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September 16, 2014 Tuesday
Late Edition - Final
U.S. to End Coverage Under Health Care Law for Tens of Thousands
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 734 words
WASHINGTON -- The Obama administration said on Monday that it planned to terminate health insurance for 115,000 people on Oct. 1 because they had failed to prove that they were United States citizens or legal immigrants eligible for coverage under the Affordable Care Act. It also told 363,000 people that they could lose financial aid because their incomes could not be verified.
The 115,000 people ''will lose their coverage as of Sept. 30,'' said Andrew M. Slavitt, the No. 2 official at the Centers for Medicare and Medicaid Services, which runs the federal insurance marketplace.
Some of them may be able to have their coverage reinstated retroactively if they produce the documents that they were repeatedly asked to provide in recent months, Mr. Slavitt said.
At the end of May, the administration said, 966,000 people were found to have discrepancies in their immigration and citizenship records. Most sent in documents as requested. In mid-August, the administration sent letters to about 310,000 people who had failed to respond. They were supposed to submit documents by Sept. 5, but the 115,000 consumers failed to do so, Mr. Slavitt said.
Many consumers and lawyers who work with them said that they had tried to submit immigration and citizenship papers, but that they experienced problems transmitting documents through HealthCare.gov. Other people said they sent the documents by mail to a federal contractor in Kentucky but never heard back from the contractor or the government.
''We heard from lots of consumers who told us they sent in their documents multiple times or tried to upload them through HealthCare.gov,'' said Mara Youdelman, a lawyer at the National Health Law Program, an advocacy group for low-income people.
Jenny Rejeske, a health policy analyst at the National Immigration Law Center, which represents immigrants, said: ''It is unduly harsh to terminate coverage while there are still technical problems with the federal system for verifying citizenship and immigration status. And there has not been adequate notice to people who speak languages other than English and Spanish.''
Florida leads the list of states whose residents are losing coverage because of immigration and citizenship issues, with 35,100. Federal officials said they were ending coverage for 19,600 people in Texas, 6,300 in Georgia, 5,300 in North Carolina, 5,200 in Pennsylvania, 4,000 in Illinois and 2,400 in New Jersey. The numbers released on Monday are for 36 states using the federal insurance marketplace. They do not include terminations in California, New York and other states running their own insurance exchanges.
Federal subsidies for the purchase of private insurance are a cornerstone of the Affordable Care Act. More than eight out of 10 people who selected health plans through the exchanges from October through mid-April were eligible for subsidies, including income tax credits. But in many cases, the government could not verify the incomes people reported when they applied for subsidized insurance.
This does not mean that they provided false information or were ineligible for assistance. The government tried to verify incomes by checking 2012 tax return information, but consumers may have switched jobs or received pay raises since filing those returns. As a result, officials said, the information in their applications may not match the data in federal files or in sources available to the government.
Mr. Slavitt said that on May 30 there were roughly 1.2 million households (and a total of 1.6 million people) with ''data-matching issues.''
Since then, the government said, it has closed cases for 467,000 households with data discrepancies, and 430,000 cases are ''currently in the process of being resolved.''
''There are still about 279,000 households with unresolved income-related data-matching issues that haven't sent in supporting information, representing 363,000 individuals,'' Mr. Slavitt said. They will soon receive letters from the government asking for proof of income, and if they do not reply by Sept. 30, they may lose some or all of their subsidies.
They would still be eligible for coverage, but in many cases could not afford it. In some cases, they would also have to repay some or all of the subsidies they received.
It is also possible that some people could receive larger subsidies if their incomes are lower than what they expected when they applied.
URL: http://www.nytimes.com/2014/09/16/us/us-to-end-coverage-under-health-care-law-for-tens-of-thousands.html
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May 21, 2013 Tuesday
The Early Word: Pre-Existing Conditions
BYLINE: JADA F. SMITH
SECTION: US; politics
LENGTH: 315 words
HIGHLIGHT: Political news from today’s Times and around the Web, plus a look at the latest happenings in Washington.
Today's Times
The cost of claims for people with serious pre-existing medical conditions has already exhausted most of the $5 billion provided by Congress in the 2010 health care law, Robert Pear writes.
Members of the bipartisan group of eight senators who drafted an overhaul of the nation's immigration laws see Senator Orrin G. Hatch, Republican of Utah and an original sponsor of the Dream Act for young immigrants, as a potentially influential partner, Ashley Parker reports. But he is playing hard to get.
Peter Baker and Jonathan Weisman delve deeper into the details released by Jay Carney, President Obama's press secretary, that go beyond a previous White House account on what the administration knew about the Internal Revenue Service's scrutiny of conservative groups.
Around the Web
The Customs and Border Protection agency presented a plan to Congress that would prevent employee furloughs brought on by the sequester, The Washington Post reports.
Washington is getting a greater share of thelimelight lately, with Amazon.com expected to produce a full season of "Alpha House," a comedy about Republican senators living together as roommates, Politico reports.
Happenings in Washington
President Obama and Vice President Joseph R. Biden Jr. will meet with young immigrants who have received deferred action on deportation, as well as American citizens who are family members of illegal immigrants, in the Oval Office.
Later, Mr. Biden will speak at a reception in honor of Jewish American Heritage Month.
The Library of Congress will host a concert in its Coolidge Auditorium in honor of the singer Carole King.
A Focus on Border Security and Temporary Visas as Senators Return to Immigration
Obama Decries Senate's Rejection of Gun Safety Measures
Senate Republicans Describe Cordial, if Not Convincing, Dinner With Obama
The Early Word: In Remembrance
The Weekend Word: The Crucible
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January 7, 2017 Saturday
Late Edition - Final
Medicare and Health Law
SECTION: Section A; Column 0; Editorial Desk; LETTER; Pg. 18
LENGTH: 196 words
To the Editor:
Re ''The Coming Health Care Crisis'' (editorial, Jan. 5):
Seniors and baby boomers should take note: The rush to repeal and delay the Affordable Care Act will harm them, too.
Like working-class Americans and their families, people with Medicare are at grave risk. Undoing the health law could increase their prescription-drug costs, eliminate access to preventive care, and roll back efforts that stabilized Medicare premiums and cost-sharing.
For people 55 to 64, more than 4.5 million could lose their coverage, and the number of those uninsured could double to nearly 20 percent. Vague replacement frameworks put forward in the past are all clear on at least one point: Insurers could charge even higher premiums than already permitted for this age group.
In fact, some such plans put no limits on how high premiums can go for people at these ages.
Before the Affordable Care Act, people under 65 called our help line every day desperate to find affordable coverage but learned that there was none. If the law is repealed, coverage will again be out of reach until they become eligible for Medicare.
JOE BAKER
President
Medicare Rights Center
New York
URL: http://www.nytimes.com/2017/01/06/opinion/medicare-and-the-health-law.html
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The New York Times
March 26, 2014 Wednesday
The New York Times on the Web
Supreme Court Hears Cases on Contraception Rule
BYLINE: By ADAM LIPTAK
SECTION: Section ; Column 0; Washington; Q. AND A.; Pg.
LENGTH: 926 words
WASHINGTON -- The Supreme Court on Tuesday will hear arguments in a pair of challenges to a part of President Obama's health care law that requires many employers to provide insurance coverage for contraceptives. Here is a look at the parties, the lawyers and the issues in the case.
Q. Who are the challengers?
A. The cases were brought by two corporations whose owners say they try to run their businesses on religious principles. One is Hobby Lobby, a chain of crafts stores owned by a Christian family. The other is Conestoga Wood Specialties, which makes wood cabinets and is owned by a Mennonite family.
Q. When will the cases be argued?
A. The justices are set to announce one or more decisions from the bench starting at 10 a.m. After that, they will hear a consolidated argument in two cases, Sebelius v. Hobby Lobby Stores, No. 13-354, and Conestoga Wood Specialties v. Sebelius, No. 13-356. The court has scheduled 90 minutes for the argument instead of the usual hour.
Q. Who will be arguing?
A. Paul D. Clement, a former United States solicitor general in the Bush administration, will argue for the companies. The current solicitor general, Donald B. Verrilli Jr., will represent the government. The two men faced off two years ago in another challenge to the Affordable Care Act, which focused on its requirement that most Americans obtain health insurance or pay a penalty. The court ruled for the Obama administration in that case by a 5-to-4 vote.
Q. When will the court issue its decision?
A. It will probably be issued in late June.
Q. What does the challenged law say?
A. A provision of the Affordable Care Act requires many employers to provide female workers with comprehensive insurance coverage for a variety of methods of contraception.
Q. Does the law apply to all employers?
A. No. Under the law and related regulations, small employers do not need to offer health coverage at all; religious employers like churches are exempt; religiously affiliated groups may claim an exemption; and some insurance plans that had not previously offered the coverage are grandfathered. In June, a federal judge in Tampa, Fla., estimated that a third of Americans are not subject to the requirement that their employers provide coverage for contraceptives.
Q. How does the administration justify the law?
A. In his briefs, Mr. Verrilli told the justices that requiring insurance plans to include comprehensive coverage for contraception promotes public health and ensures that ''women have equal access to health care services.'' He added that doctors, rather than employers, should decide which form of contraception is best. A supporting brief from the Guttmacher Institute, a research and policy group, said that many women cannot afford the most effective means of birth control and that the law will reduce unintended pregnancies and abortions.
Q. What is the companies' objection?
A. They say that some contraceptive drugs and devices are tantamount to abortion because they can prevent embryos from implanting in the womb. Providing insurance coverage for those forms of contraception would, they say, make them complicit in the practice. They said they had no objection to other forms of contraception approved by the Food and Drug Administration, including condoms, diaphragms, sponges, several kinds of birth control pills and sterilization surgery.
Q. Do for-profit companies and their owners have the right to object on religious grounds?
A. The lower courts are divided over whether for-profit corporations have rights under the First Amendment's free exercise clause and the federal law at the heart of Tuesday's cases, the Religious Freedom Restoration Act of 1993. In weighing the question, the Supreme Court may consider whether its 2010 decision in Citizens United, which said corporations have free speech rights under the First Amendment, suggests that they also have the right to religious liberty.
Q. What is the Religious Freedom Restoration Act?
A. The law was a response to a 1990 Supreme Court decision that declined to recognize religious exceptions under the First Amendment's free exercise clause to generally applicable laws. Congress effectively reversed that decision. ''What this law basically says,'' President Bill Clinton said before signing the bill, ''is that the government should be held to a very high level of proof before it interferes with someone's free exercise of religion.''
Q. How will the justices analyze the case under the 1993 law?
A. If the companies or their owners may raise a religious freedom claim, the court will first consider whether the contraception coverage requirement imposes a ''substantial burden'' on religious practices. Hobby Lobby says that its failure to offer comprehensive coverage could subject it to federal fines of $1.3 million a day and that dropping insurance coverage for its employees would be disruptive and unfair and lead to fines of $26 million a year. The law's defenders say the company would be better off financially if it dropped coverage and so does not face a substantial burden.
Q. What happens if the court agrees that the law imposes a substantial burden?
A. The justices will then test the coverage requirement against a demanding legal test, asking whether the government has shown that it is ''the least restrictive means of furthering'' a ''compelling governmental interest.'' The companies say the administration cannot meet either part of that standard because its justifications for the law are too broad and vague and because of the many exemptions it has granted.
URL: http://www.nytimes.com/2014/03/26/us/politics/q-and-a-on-challenges-to-health-laws-birth-control-requirement.html
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The New York Times
December 1, 2012 Saturday
Late Edition - Final
The Cost of Change
BYLINE: By REED ABELSON and STEVEN GREENHOUSE
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1
LENGTH: 1286 words
Like many franchisees, Robert U. Mayfield, who owns five Dairy Queens in and around Austin, Tex., is always eager to expand and -- no surprise -- has had his eyes on opening a sixth DQ. But he said concerns about the new federal health care law had persuaded him to hold off.
''I'm scared to death of it,'' he said. ''I'm one of the ones sitting on the sidelines to see what's really going to happen.''
Mr. Mayfield, who has 99 employees, said he was worried he would face penalties of $40,000 or more because he did not offer health insurance to many of his full-time workers -- generally defined as those working an average of 30 hours a week or more. Ever since the law was enacted in 2010, opponents have argued that employers who were forced to offer health insurance would lay off workers or shift more people to part-time status to compensate for the additional cost. Those claims have drawn considerable attention -- and considerable anger in response -- in recent weeks.
John H. Schnatter, the chief executive of Papa John's, the pizza chain, said some franchisees were likely to reduce their employees' hours to avoid having to provide coverage. And an unhappy Denny's franchise owner in Florida warned that he would raise prices 5 percent as a ''surcharge,'' adding that disgruntled customers could offset that by reducing their tips.
Some health care experts said comments like those came from outliers and sometimes resulted from confusion about a highly complicated new law, the Patient Protection and Affordable Care Act. Many of the provisions do not go into effect until 2014. Federal officials are still tweaking the fine print, like defining exactly what constitutes a 30-hour workweek. Even so, restaurants and hotels are among the industries likely to be squeezed the hardest by the law because they are low-wage industries that do not offer coverage to most of their workers.
Most employers, even small businesses, already offer health insurance, and the federal law is not expected to have a significant impact on what they do over the next year or so. But businesses that rely heavily on low-income workers, many of whom do not make enough to afford their share of the cost of the insurance premiums, are being forced to rethink their business models.
Almost half of retail and hospitality employers do not offer coverage to all their full-time employees, according to a recent survey by Mercer, a benefits consultant.
''They're all developing their strategies,'' said Debra Gold, a senior partner with Mercer who advises several major retailers.
Many who oppose the requirement say the cost of providing health insurance could mean hiring fewer workers. ''Any dollar that gets diverted, whether it's through Obamacare or increased tax rates, puts franchisees one dollar further away from being able to expand their businesses,'' said Don Fox, chief executive of Firehouse Subs, a fast-growing chain of 559 restaurants based in Jacksonville, Fla. At the 30 stores the corporation owns, only full-time managers are offered coverage. Mr. Fox is wrestling with whether to absorb the considerable cost of covering 100 more employees or pay the penalties -- which would probably cost him less -- but risk losing valued employees to competitors who choose to offer coverage.
Employee health coverage now averages nearly $6,000 for an individual plan. That is considerable for businesses like restaurants in which the majority of workers make $24,000 a year or less, according to research by the Kaiser Family Foundation. The foundation found that only 28 percent of companies that employ large numbers of low-income workers offer health benefits. ''This is where the biggest set of hurdles is,'' said Gary Claxton, an executive with Kaiser.
By 2014, businesses with 50 or more full-time employees will be expected to offer as yet undefined affordable coverage, based on an employee's income. For employers that fail to offer such coverage, the law typically calls for a penalty of $2,000 a worker, excluding the first 30 employees. As evidence of how sensitive the issue is, Mr. Schnatter of Papa John's took some heat for his initial statements about the possibility that franchisees would cut employees' hours to avoid penalties or having to provide coverage. His comments, made during a public appearance, were reported by a local newspaper in Florida, The Naples News. After facing a storm of criticism, he wrote an opinion piece for The Huffington Post, in which he said he had only been speculating about the law's potential impact on franchisees.
''Papa John's, like most businesses, is still researching what the Affordable Care Act means to our operations,'' he wrote. ''Regardless of the conclusion of our analysis, we will honor this law, as we do all laws, and continue to offer 100 percent of Papa John's corporate employees and workers in company-owned stores health insurance as we have since the company was founded in 1984.'' Through a spokesman, Mr. Schnatter declined to comment further.
Some business owners and consultants warn that opting to have more part-time workers, perhaps by converting some full-timers to part-time status, may not be the answer because many workers might decide to find jobs elsewhere.
''When you explain this to your employee who really needs the income, maybe they'll try to get a second job,'' said Mr. Fox, Firehouse's chief executive. ''Maybe they'll try to get another full-time job and maybe a job that provides health care. There will be an incentive for the best people to search for those jobs.''
Ms. Gold, of Mercer, said that when one employer analyzed what might happen if the company moved to more part-time workers, it realized that its losses in productivity would outweigh any savings on insurance costs.
Employers -- often with a mixture of impatience and confusion -- are waiting for the Obama administration to issue final rules on some of the law's crucial aspects, like how the government determines whether an employee meets the 30-hour threshold, given the large numbers of seasonal and part-time workers with varying hours. Similarly, the precise level of coverage an employer must provide has not yet been clearly defined.
''If you can tell me what Obamacare is, then I can tell you how much it's going to affect me,'' said Bob Bellagamba, who runs Concorde Limousine, a service with 75 employees, in Freehold, N.J. ''All the reading I've done on this, and there are so many things that are not determined. There is no clarity to the guidelines.''
In contrast to the resistance in the hospitality industry, some small business owners say the health care law has made coverage more affordable.
Lisa Goodbee, who runs a civil engineering firm in a Denver suburb, decided to offer health coverage to her 15 employees this year for the first time in the firm's 20-year history. She said the Affordable Care Act was a major reason. In past years, she said, the quotes she got from health insurers were ''ridiculous''; this year, she said, they were far more reasonable.
''We're an engineering company and we need to hire the best of the best,'' she said, acknowledging that not offering health insurance made that difficult.
Ron Nelsen, who operates Pioneer Overhead Door, a Las Vegas business with five employees that installs garage doors, says he has already received the tax credits the law makes available to businesses with fewer than 25 employees that offer coverage.
''They're in the bank,'' he said.
Mr. Nelsen dismissed the notion that employers like him weigh the cost of providing health insurance in deciding whether to hire someone new. ''You know what makes jobs? Consumer demand,'' he said. ''I hire people when demand necessitates it.''
URL: http://www.nytimes.com/2012/12/01/business/small-employers-weigh-impact-of-providing-health-insurance.html
LOAD-DATE: December 4, 2012
LANGUAGE: ENGLISH
GRAPHIC: PHOTOS: Robert Mayfield, who owns Dairy Queen franchises in Texas, says he is ''scared to death'' of the new health care law. (PHOTOGRAPH BY ERICH SCHLEGEL FOR THE NEW YORK TIMES) (B1)
Bob Bellagamba, who runs Concorde Limousine in Freehold, N.J., says there is too much uncertainty about the new law. (PHOTOGRAPH BY LAURA PEDRICK FOR THE NEW YORK TIMES)
Don Fox, chief of Firehouse Subs, says providing health insurance would mean less money for expanding his business. (PHOTOGRAPH BY KELLY JORDAN FOR THE NEW YORK TIMES) (B3)
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January 20, 2016 Wednesday
Bill Clinton Warns of 'Gridlock' Under Bernie Sanders's Health Care Plan
BYLINE: NICK CORASANITI
SECTION: US; politics
LENGTH: 310 words
HIGHLIGHT: Bill Clinton makes nice to Bernie Sanders, then wonders if the senator could ever succeed in getting his priorities through Congress.
Bill Clinton acknowledged he was in Senator Bernie Sanders's backyard as he took the stage Wednesday in New Hampshire.
"I know we're running against one of your neighbors," Mr. Clinton told the crowd at a campaign rally in Concord.
So, as he laid out the differences between Mr. Sanders and Hillary Clinton, he did so with compliments before dwelling on the contrasts.
On the water crisis in Flint, Mich., he said that Mr. Sanders "genuinely cared about it," before adding that Mrs. Clinton looked for a solution while Mr. Sanders called for the governor to resign. (Mr. Sanders did that only after saying he agreed with what Mrs. Clinton had said initially.)
On the economy, Mr. Clinton said that both candidates wanted "shared prosperity and less inequality," but that Mr. Sanders was more about demonizing and breaking up big banks while Mrs. Clinton believed the financial crash was "caused mostly by the failure of government."
But on health care, he took a more direct criticism of Mr. Sanders's plan: "I don't want to talk about the merits, I want to talk about the practical reality here."
What followed was the legislative history of the Affordable Care Act in which he listed the difficulty in simply getting it passed - "we had not a vote to spare" - while noting that was with a Democratic supermajority in the Senate and a Democratic-led House. He said that while he thought the Democrats would win back the Senate in November, the House would likely stay Republican, making passing any legislation difficult.
That history lesson was part of Mr. Clinton's argument that Mr. Sanders's plan for a single-payer health care system was simply not feasible.
"It's a recipe for gridlock," Mr. Clinton said.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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The New York Times
September 14, 2014 Sunday
Late Edition - Final
Rashi Fein, 88, Economist Who Urged Medicare, Dies
BYLINE: By DOUGLAS MARTIN
SECTION: Section A; Column 0; Obituary; Pg. 26
LENGTH: 886 words
Rashi Fein, an influential economist who strove to bring ethical and humanitarian perspectives to the nation's health care system and helped lay the intellectual groundwork for Medicare in the 1960s, died on Monday in Boston. He was 88.
The cause was melanoma, his son Alan said.
When Dr. Fein began working on health issues as a young aide in the administration of Harry S. Truman, health care accounted for about 3 percent of the American economy. By the time he weighed in as a respected elder in the field during the debate over President Obama's health care proposals, the expenditures had risen to 18 percent, an amount roughly equal to the economy of France.
As the money Americans spent on medical care increased, so did the role of economists specializing in health issues. Dr. Fein moved between government and academia, offering research and views on issues like meeting the demand for physicians. During the administration of President Lyndon B. Johnson, he led a public-private panel to develop ideas for the Medicare legislation, which, along with Medicaid, was signed into law in 1965.
Dr. Fein, a proud liberal, regretted that Medicare did not apply to everyone, just as he was disappointed that Mr. Obama's Affordable Care Act did not consolidate insurance payments under the federal government. A federal single-payer system, he maintained, would be more cost effective and inclusive. The Obama plan, passed by Congress, relies on private insurance.
But Dr. Fein was nonetheless satisfied with incremental progress, Dr. Ezekiel J. Emanuel, chairman of the department of medical ethics and health policy at the University of Pennsylvania, said in an interview on Thursday. He quoted Dr. Fein, a former professor of his, as saying, ''Getting everybody under the tent is better than standing on principle and not getting anything.''
Dr. Fein regarded both Medicare and the Affordable Care Act as important steps toward the overriding goal of helping ''the people who have the least,'' Dr. Emanuel said. In his 1986 book, ''Medical Care, Medical Costs: The Search for a Health Insurance Policy,'' Dr. Fein wrote, ''Decent people -- and we are decent people -- are offended by unnecessary pain and suffering; that is, by pain and suffering for which there is a treatment and for which some (who are affluent) are treated.''
Mr. Fein was born in the Bronx on Feb. 6, 1926. His father, Isaac, was a history professor whose work took him to a chain of cities in the United States and Canada, including Winnipeg, Manitoba; and Bridgeport, Conn. His mother, the former Chaya Wertheim, was a schoolteacher.
Mr. Fein's son Alan said his father and his father's younger brother, Leonard -- who went on to found organizations to combat hunger -- had gotten their zeal for social justice from their parents.
''My preference for a universal insurance program derives from my image of a just society,'' Dr. Fein wrote in his 1986 book. ''It is an image based on a broadly defined concept of justice and liberty, nurtured by stories my parents told me, the books they encouraged me to read, and the values they expressed. To them, liberty meant more than political freedom; it also meant freedom from destitution -- in Roosevelt's phrase, 'freedom from want.' ''
After graduating from Central High School in Bridgeport, Dr. Fein was a Navy radar technician during World War II. He went on to earn a bachelor's degree in economics and a doctorate in political economy from Johns Hopkins University.
In 1952, he took a teaching post at the University of North Carolina at Chapel Hill, while working on a Truman administration commission charged with exploring the possibilities for national health insurance.
Six years later, he led a study by the federal Joint Commission on Mental Illness and Health, which estimated that mental illness cost the United States $3 billion a year ($24.7 billion in today's dollars) in treatment costs and lost work years, a small fraction of the estimated costs today.
In 1961, Dr. Fein became a senior staff member on the Council of Economic Advisers under President John F. Kennedy. He studied education issues in addition to helping to write legislation for Medicare. He moved on to the Brookings Institution as a senior fellow in 1963 and remained with it while directing the Medicare panel for Johnson, Kennedy's successor.
After leaving Brookings, Dr. Fein was a professor of economics at the Kennedy School of Government and the Medical School of Harvard University. He retired in 1999.
In addition to his son Alan, Dr. Fein is survived by his wife of 65 years, the former Ruth Judith Breslau; another son, Michael; a daughter, Karen Fein; and four grandchildren. Another daughter, Bena Fein, died in 1995. Dr. Fein's brother, Leonard, died in August.
Dr. Fein spoke of the importance of language in describing health care, deriding the term ''death panels'' that some opponents used in the debate over the Affordable Care Act.
''A new language is infecting the culture of American medicine,'' he wrote in The New England Journal of Medicine in 1982. ''It is the language of the marketplace, of the tradesman, and of the cost accountant. It is a language that depersonalizes both patients and physicians and describes medical care as just another commodity. It is a language that is dangerous.''
URL: http://www.nytimes.com/2014/09/14/us/rashi-fein-economist-who-urged-medicare-dies-at-88.html
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GRAPHIC: PHOTO: Rashi Fein in 2000. He called for universal health coverage. (PHOTOGRAPH BY MICHAEL FEIN)
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The New York Times
June 23, 2016 Thursday
Late Edition - Final
Report Sees Shortfalls for Benefit Programs
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 867 words
WASHINGTON -- The Obama administration said Wednesday that the financial outlook for Medicare's hospital insurance trust fund had deteriorated slightly in the last year and that Social Security still faced serious long-term financial problems.
The report, from the trustees of the two programs, could inject a note of fiscal reality into a presidential campaign that has given scant attention to the government's fiscal challenges as the population ages. Hillary Clinton, the presumptive Democratic presidential nominee, has proposed increasing Social Security benefits and allowing people age 55 to 64 to ''buy into'' Medicare, while Donald J. Trump, the presumptive Republican nominee, has repeatedly said he would not cut either program.
Under existing law, the trustees said Wednesday, Medicare's hospital trust fund would be depleted in 2028, two years earlier than projected in last year's report.
In addition, they said, the Social Security trust funds for old-age benefits and disability insurance, taken together, could be depleted in 2034, the same year projected in last year's report. Tax collections would then be sufficient to pay about three-fourths of promised benefits through 2090, they said.
Social Security and Medicare account for about 40 percent of all federal spending.
Obama administration officials often say the Affordable Care Act has slowed the growth of health spending, compared with estimates made just before the law was adopted in 2010.
But the trustees said Wednesday that the short-term financial outlook for Medicare had worsened in the last year because of changes in their assumptions and expectations. Medicare actuaries now expect higher use of inpatient hospital services, as well as lower projected improvements in workers' productivity and lower payroll tax revenue, as a result of slower growth in wages in the next few years.
In their report, the trustees -- four administration officials -- said that the costs of Medicare and Social Security would grow faster than the economy through the mid-2030s because of the aging of the baby boom generation. As for Medicare, they said, ''growth in expenditures per beneficiary exceeds growth in per capita gross domestic product over this time period.''
The projected growth in Medicare spending will not immediately set off automatic cuts in the program under a controversial provision of the Affordable Care Act that generally requires such cuts when spending is expected to exceed certain benchmarks. However, such cuts could be required in a few years under the trustees' forecast.
Under current projections, they said, the automatic cuts could take effect for the first time in 2019.
Medicare now spends an average of nearly $13,000 per beneficiary, and this figure is expected to exceed $16,000 in five years, the report said.
''High-cost drugs are a major driver of Medicare spending growth,'' said Andrew M. Slavitt, the acting administrator of the federal Centers for Medicare and Medicaid Services.
Such projections in years past have prompted leaders in both parties to at least broach the idea of benefit cuts or tax increases for entitlement programs.
By contrast, President Obama said in Elkhart, Ind., this month that Social Security should be made ''more generous,'' and that ''we could start paying for it by asking the wealthiest Americans to contribute a little bit more.''
Treasury Secretary Jacob J. Lew said Wednesday that he saw no contradiction there. The two objectives -- ensuring the solvency of Social Security and increasing benefits -- are ''not at all inconsistent'' if they are discussed in the context of ''a broader conversation'' about taxes and benefits, he said.
The report predicts that Social Security will provide a modest cost-of-living adjustment, increasing benefits by two-tenths of 1 percent next year. But, it warned of a ''substantial increase'' in Medicare premiums in 2017 for about 30 percent of beneficiaries. Under assumptions in the report, the standard premium, now $121.80 a month, would rise to $149, and the change could be announced just weeks before Election Day on Nov. 8.
Congress took action last year to shore up Social Security's disability insurance trust fund, but the report says the legislation was a short-term fix. The law postponed the projected depletion of the disability trust fund by seven years, to 2023, Mr. Lew said.
Like other Democrats, Mr. Lew said the report showed the ''positive impact'' of the Affordable Care Act. Since the health law was signed, he said, ''increases in health care costs have slowed substantially.''
Carolyn W. Colvin, the acting commissioner of Social Security, said Americans should begin a serious discussion of how to close the ''future financing gap'' in Social Security. Sixty million people now receive Social Security benefits totaling more than $74 billion each month. The number of Social Security beneficiaries is expected to reach 76 million by 2025.
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This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/2016/06/23/us/politics/medicare-social-security-trustees-report.html
LOAD-DATE: June 23, 2016
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GRAPHIC: PHOTO: Carolyn W. Colvin, the acting commissioner of Social Security, during a news conference in Washington on Wednesday. (PHOTOGRAPH BY ANDREW HARNIK/ASSOCIATED PRESS)
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The New York Times
January 11, 2014 Saturday
Late Edition - Final
Understanding New Rules That Widen Mental Health Coverage
BYLINE: By ANN CARRNS
SECTION: Section B; Column 0; Business/Financial Desk; YOUR MONEY ADVISER; Pg. 4
LENGTH: 880 words
Long-awaited improvements in insurance coverage for mental conditions and addictions are expected to become more widely available this year as a result of two major steps that the Obama administration has taken.
The president's signature Affordable Care Act includes mental health care and substance abuse treatment among its 10 ''essential'' benefits, which means plans sold on the public health care exchanges must include coverage.
In addition, rules to fully carry out an older law -- the Mental Health Parity and Addiction Equity Act of 2008 -- were issued in November, after a long delay. The parity law says that when health insurance plans provide coverage for mental ailments, it must be comparable to coverage for physical ailments. For instance, plans cannot set higher deductibles or charge higher co-payments for mental health visits than for medical visits, and cannot set more restrictive limits on the number of visits allowed.
The new parity rules apply to most health plans and are effective beginning July 1, although many plans will not have to comply until January of next year.
While many plans are already complying with certain aspects of parity, the final rules fill in gaps about how the law must be applied, advocates say. For instance, plans cannot limit mental health care to a specific geographic region, if they do not do so for physical illnesses. And the rules clarify that the law also applies to ''intermediate'' treatment options for mental health and addiction disorders, like residential treatment or intensive outpatient therapy.
Insurance plans also must be consistent when deciding whether treatment for physical or mental ailments is medically necessary, and they cannot make getting prior-approval for inpatient mental health treatment more difficult than that for admission to an acute care hospital, said Andrew Sperling, director of federal legislative advocacy at the National Alliance on Mental Illness. They must also let patients and doctors know what criteria are used to make those decisions, which can be helpful if coverage is denied and a patient wants to file an appeal.
In the past, when health plans offered mental health coverage, it was often at less generous levels than benefits for medical care, said Debbie Plotnick, senior director of state policy at Mental Health America, an advocacy group. ''All these discriminatory practices kept people from getting mental health care, and they are no longer allowed under the parity law,'' she said.
Still, consumers will have to take time to understand details of their health coverage, so they can raise questions if they think their plans do not follow the rules, said Carol McDaid, a lobbyist specializing in behavioral health issues. ''Consumers have to know what their rights and benefits are,'' she said.
Expanding insurance coverage does not necessarily mean everyone who needs care can easily find it. Many office-based psychiatrists, for instance, do not accept insurance, partly because reimbursement for services has been inadequate. A study published in December in the journal JAMA Psychiatry found that only about half of psychiatrists accept private insurance.
It's also still unclear just how the parity rules apply to some coverage under Medicaid, the federal-state health plan for low-income people; further guidance is expected on that, advocates say. (The parity law does not apply to Medicare, the federal health plan for people 65 and older. But payment for psychological services under Medicare is now comparable to that for medical services, under the requirements of a different law.)
Here are some questions to consider:
â- What should I look for when evaluating a plan's mental-health benefits?
Advocates say one of the most important features to consider is a plan's network of mental health professionals. Check to see if providers are in your area; otherwise, you may pay higher fees for seeing an out-of-network therapist.
â- What if my health plan is unfairly restricting mental health benefits, or has denied my claim?
The Parity Implementation Coalition, formed to promote compliance with the law, offers a tool kit to help you file an appeal, at parityispersonal.org. Steps beyond an appeal with your insurer depend on what type of plan you have. For instance, private companies that buy insurance for their employees, rather than paying claims directly, are considered ''insured'' and generally are regulated by state insurance departments. But if your company is ''self-funded'' and pays health claims directly, your appeal most likely would be handled by the federal Labor Department. Coverage through state or local governments, meanwhile, may be regulated by the federal Health and Human Services Department. If you don't know what kind of plan you have, call your plan administrator and ask.
â- What if I can't find a therapist who accepts my insurance?
Contact your county behavioral health department, which coordinates mental health care and can help you find affordable treatment. The federal Substance Abuse and Mental Health Services Administration also offers a service locater, samhsa.gov/treatment/index.aspx on its website.
Email: yourmoneyadviser@nytimes.com
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/2014/01/10/your-money/understanding-new-rules-that-widen-mental-health-coverage.html
LOAD-DATE: January 11, 2014
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GRAPHIC: PHOTO: The Affordable Care Act includes substance abuse treatment among its 10 ''essential'' benefits. (PHOTOGRAPH BY JESSICA KOURKOUNIS FOR THE NEW YORK TIMES)
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The New York Times
June 29, 2012 Friday
Late Edition - Final
The Real Winners
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 25
LENGTH: 802 words
So the Supreme Court -- defying many expectations -- upheld the Affordable Care Act, a k a Obamacare. There will, no doubt, be many headlines declaring this a big victory for President Obama, which it is. But the real winners are ordinary Americans -- people like you.
How many people are we talking about? You might say 30 million, the number of additional people the Congressional Budget Office says will have health insurance thanks to Obamacare. But that vastly understates the true number of winners because millions of other Americans -- including many who oppose the act -- would have been at risk of being one of those 30 million.
So add in every American who currently works for a company that offers good health insurance but is at risk of losing that job (and who isn't in this world of outsourcing and private equity buyouts?); every American who would have found health insurance unaffordable but will now receive crucial financial help; every American with a pre-existing condition who would have been flatly denied coverage in many states.
In short, unless you belong to that tiny class of wealthy Americans who are insulated and isolated from the realities of most people's lives, the winners from that Supreme Court decision are your friends, your relatives, the people you work with -- and, very likely, you. For almost all of us stand to benefit from making America a kinder and more decent society.
But what about the cost? Put it this way: the budget office's estimate of the cost over the next decade of Obamacare's ''coverage provisions'' -- basically, the subsidies needed to make insurance affordable for all -- is about only a third of the cost of the tax cuts, overwhelmingly favoring the wealthy, that Mitt Romney is proposing over the same period. True, Mr. Romney says that he would offset that cost, but he has failed to provide any plausible explanation of how he'd do that. The Affordable Care Act, by contrast, is fully paid for, with an explicit combination of tax increases and spending cuts elsewhere.
So the law that the Supreme Court upheld is an act of human decency that is also fiscally responsible. It's not perfect, by a long shot -- it is, after all, originally a Republican plan, devised long ago as a way to forestall the obvious alternative of extending Medicare to cover everyone. As a result, it's an awkward hybrid of public and private insurance that isn't the way anyone would have designed a system from scratch. And there will be a long struggle to make it better, just as there was for Social Security. (Bring back the public option!) But it's still a big step toward a better -- and by that I mean morally better -- society.
Which brings us to the nature of the people who tried to kill health reform -- and who will, of course, continue their efforts despite this unexpected defeat.
At one level, the most striking thing about the campaign against reform was its dishonesty. Remember ''death panels''? Remember how reform's opponents would, in the same breath, accuse Mr. Obama of promoting big government and denounce him for cutting Medicare? Politics ain't beanbag, but, even in these partisan times, the unscrupulous nature of the campaign against reform was exceptional. And, rest assured, all the old lies and probably a bunch of new ones will be rolled out again in the wake of the Supreme Court's decision. Let's hope the Democrats are ready.
But what was and is really striking about the anti-reformers is their cruelty. It would be one thing if, at any point, they had offered any hint of an alternative proposal to help Americans with pre-existing conditions, Americans who simply can't afford expensive individual insurance, Americans who lose coverage along with their jobs. But it has long been obvious that the opposition's goal is simply to kill reform, never mind the human consequences. We should all be thankful that, for the moment at least, that effort has failed.
Let me add a final word on the Supreme Court.
Before the arguments began, the overwhelming consensus among legal experts who aren't hard-core conservatives -- and even among some who are -- was that Obamacare was clearly constitutional. And, in the end, thanks to Chief Justice John Roberts Jr., the court upheld that view. But four justices dissented, and did so in extreme terms, proclaiming not just the much-disputed individual mandate but the whole act unconstitutional. Given prevailing legal opinion, it's hard to see that position as anything but naked partisanship.
The point is that this isn't over -- not on health care, not on the broader shape of American society. The cruelty and ruthlessness that made this court decision such a nail-biter aren't going away.
But, for now, let's celebrate. This was a big day, a victory for due process, decency and the American people.
URL: http://www.nytimes.com
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The New York Times Blogs
(Fiscal Crisis)
September 30, 2013 Monday
House May Consider Short-Term Financing Measure
BYLINE: Jeremy W. Peters
SECTION: US
LENGTH: 284 words
HIGHLIGHT: One possible way out of a government shutdown would be a bill that extends the federal budget by a few days or so, enabling Congressional leaders to continue seeking a resolution.
One possible way out of a government shutdown would be a bill that extends the federal budget by a few days or so, enabling Congressional leaders to continue seeking a resolution.
House Republicans have said that they will consider attaching a short-term funding measure to whatever else they send back to the Senate for consideration in the next round of dueling spending bills.
But Senate Democrats are cool to the idea, even if they would face considerable pressure to approve it. Aides to the Democratic leadership said Monday that they saw little point in passing anything that would effectively drag the fighting out longer.
They said that Senator Harry Reid, the majority leader, remained steadfast in his position that he will accept nothing other than a straight-up budget bill, free of any Republican policy prescriptions like a delay in the implementation of the Affordable Care Act. Another week will not change that, they said.
Other Democrats also appear reluctant. Senator Barbara Boxer of California resisted the idea of a stopgap on Monday, saying of House Republicans, "They have to grow up and just step up to the plate."
She called on Speaker John A. Boehner to resist the conservative members of his party and allow the Senate budget bill to come to the floor, where it would almost certainly pass. "That's what a speaker is supposed to do," she said. "They're not speaker of the Democrats or speaker of the Republicans. Act like a speaker of the House."
Obama Says He Isn't Resigned to a Shutdown
House to Meet Monday Afternoon to Plan Next Move
Boehner Shows No Signs of Backing Down
Senate Votes to Strip Budget of G.O.P. Provisions
Disability Rights Group Rallies in Support of Health Law
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The New York Times
December 6, 2016 Tuesday 00:00 EST
What Are Your Reactions to President-Elect Trump's Cabinet Appointments?;
Student Opinion
BYLINE: CAROLINE CROSSON GILPIN
SECTION: LEARNING
LENGTH: 1041 words
HIGHLIGHT: After reading the job duties and background information for each person selected for a cabinet or staff position, tell us what you think.
From George Washington's presidency until today, the president of the United States has always had a cabinet, a group of close advisers who help him make decisions about how to run the country. Since winning the election, President-elect Donald J. Trump has named many of the individuals he will nominate to serve as members of his cabinet.
Have you been following the news about Mr. Trump's cabinet selections? What's your reaction so far?
In "Carson Is New Sign Trump Plans to Govern From the Right," Michael D. Shear writes:
President-elect Donald J. Trump is moving to repudiate vast parts of President Obama's domestic agenda as he fills his cabinet with conservatives who have long records opposing the current administration on social programs, wages, public lands, veterans and the environment.
Mr. Trump's selections to lead the Departments of Education, Commerce, Justice, and Health and Human Services, and the names under consideration for other federal agencies with broad authority over the lives of Americans, have cheered Republicans in Washington, who have spent eight years battling Mr. Obama's administration.
Scan "Donald Trump Is Choosing His Cabinet. Here's the Latest List" to read brief summaries of the duties for each job, as well as background information on each person selected.
Here is a sampling of nominees Mr. Trump has announced so far:
Cabinet
Housing and Urban Development - Ben Carson
Mr. Trump has selected the former neurosurgeon and presidential candidate to be his nominee to lead HUD. Mr. Carson has said he does not want to work in government, and it was not clear whether he had accepted the offer.
The secretary oversees fair-housing laws, the development of affordable housing and access to mortgage insurance. As a real estate developer, Mr. Trump is attuned to the tax breaks for housing development.
Health and Human Services - Tom Price
Mr. Trump has selected Mr. Price, a six-term Republican congressman from Georgia and orthopedic surgeon who has led opposition to the Affordable Care Act. Mr. Price has said the law interferes with the ability of patients and doctors to make medical decisions.
The secretary will help Mr. Trump achieve one of his central campaign promises: to repeal and replace the Affordable Care Act. The department approves new drugs, regulates the food supply, operates biomedical research and runs Medicare and Medicaid, which insure more than 100 million people.
Education - Betsy DeVos
Mr. Trump has selected Ms. DeVos, a former chairwoman of the Michigan Republican Party and an education activist who is a passionate believer in school choice, as his nominee.
Mr. Trump has said he wants to drastically shrink the Education Department and shift responsibilities for curriculum research, development and educational aid to state and local governments.
United Nations - Nikki R. Haley
Mr. Trump has selected Ms. Haley, the governor of South Carolina, as his nominee. The daughter of immigrants from India, she was a prominent and frequent critic of Mr. Trump early in his run.
Second to the secretary of state, the United States ambassador to the United Nations will be the primary face of America to the world, representing the country's interests at the Security Council on a host of issues, including Middle East peace and nuclear proliferation.
Attorney General - Jeff Sessions
Mr. Trump has selected Senator Sessions, of Alabama, as his nominee. Mr. Sessions is a strong proponent of strict immigration enforcement, reduced spending and tough-on-crime measures. His nomination for a federal judgeship in 1986 was rejected because of racially charged comments and actions, which are very likely to become an issue as he faces another set of Senate confirmation hearings.
The nation's top law enforcement official will have the authority for carrying out Mr. Trump's "law and order" platform. The nominee can change how civil rights laws are enforced.
Four other cabinet nominees summarized in the article are:
Treasury - Steven Mnuchin
Transportation - Elaine L. Chao
Commerce - Wilbur Ross
Central Intelligence Agency - Mike Pompeo
Staff
Reince Priebus - Chief of Staff
Mr. Trump announced on Nov. 13 that he had chosen Mr. Priebus, the chairman of the Republican National Committee.
The chief of staff manages the work and personnel of the West Wing, steering the president's agenda and tending to important relationships. The role will take on outsize importance in a White House run by Mr. Trump, who has no experience in policy making and little in the way of connections to critical players in Washington.
Stephen K. Bannon - Chief Strategist
Also on Nov. 13, Mr. Trump announced the appointment of Mr. Bannon, a right-wing media executive and the chairman of the president-elect's campaign. Many have denounced the move, warning that Mr. Bannon represents racist views.
Stephen K. Bannon was also considered for chief of staff, but Mr. Trump instead named him chief strategist and senior counselor in the White House, saying that he and Mr. Priebus would be "working as equal partners" in the administration.
Students: Read the entire article, then tell us:
- Have you been paying attention to Mr. Trump's cabinet picks? Is there any one pick that interests you in particular? Why?
- What do you think of the group as a whole? Do they generally seem like competent and qualified choices?
- Do you approve of this group's general conservative shift toward opposing the current administration on social programs, wages, public lands, veterans and the environment? Why or why not?
- What do you think these appointments might say about a Trump presidency?
- How might these choices affect your life or the lives of those around you? For instance, as a student, what effects might the choice of Betsy DeVos, who is "passionate about the idea of steering public dollars away from traditional public schools," have on your education?
To see President Obama's current cabinet and staff, their professional backgrounds and where each job falls in line of succession from the president, check out the White House's website.
Students 13 and older are invited to comment. All comments are moderated by the Learning Network staff, but please keep in mind that once your comment is accepted, it will be made public.
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The New York Times
December 17, 2013 Tuesday
Late Edition - Final
A Gap in the Affordable Care Act
BYLINE: By CATHERINE SAINT LOUIS
SECTION: Section D; Column 0; Science Desk; Pg. 1
LENGTH: 1258 words
The Affordable Care Act mandated that insurers cover dental care for children. Indeed, it was one of the 10 essential health benefits meant to set the bar for adequate health insurance.
But pediatric dental care is handled differently from coverage of other essential benefits on federal and state exchanges. These plans are often sold separately from medical insurance, and dental coverage for children is optional. People shopping on the exchanges are not required to buy it and do not receive financial support for buying it.
Now experts are warning that the flawed implementation of this benefit on the exchanges could leave millions of children without access to dental care.
''It's letting kids down in my mind, and it is clearly inconsistent with congressional intent,'' said Dr. Paul Reggiardo, the chair of the American Academy of Pediatric Dentistry's Council on Dental Benefit Programs. ''The intent was to include all children. Now it only includes some.''
Tooth decay is the most common chronic childhood disease. Fourteen percent of children age 6 to 19 have untreated cavities, which can cause pain and, in rare cases, death. But the percentage of uninsured children who see a dentist annually declined to 25.2 percent in 2011 from 31.5 percent in 2003, according to the American Dental Association.
Had pediatric dental insurance remained a mandatory purchase on the new insurance exchanges, as originally envisioned, roughly three million children would have gained coverage this way by 2018, according to an analysis by the dental association. Pediatric dental coverage ''has gone from a guarantee to a quote-unquote guarantee,'' said Andrew Snyder, a program manager at the National Academy for State Health Policy.
On the state and federal exchanges, children's dental coverage generally comes in two forms. It may be ''embedded'' in medical insurance plans or sold separately in ''stand-alone'' plans.
Both options are not available on every exchange, though they often coexist. State exchanges in New York and Massachusetts, and most of those run by the federal government, offer a choice of health plans with or without embedded pediatric dental benefits and stand-alone dental plans.
Generally, it is the stand-alone dental plans that worry policy experts and deter consumers on the exchanges.
Recently, Blake Barkley, 44, a soccer coach in Simi Valley, Calif., logged onto the state exchange, Covered California, to find cheaper insurance for his family. He wanted a medical plan that included dental benefits like cleanings for his children, ages 4 and 8, but was dismayed that the only way to buy children's dental coverage was through an added stand-alone plan.
One problem: Stand-alone dental plans don't qualify for subsidies, as do medical plans on the exchange. With a household income of $50,000, the Barkleys qualified for a $741 annual subsidy to help pay the premiums for medical insurance. They won't receive any additional subsidy for the children's dental plan.
Mr. Barkley plans to pay for the coverage anyway. ''Stand-alone plans seem rather ridiculous to me,'' he said. ''Your teeth are part of your body.''
An embedded plan would provide subsidized coverage, but there isn't one on the California exchange. By contrast, all health plans on the exchanges in Connecticut, the District of Columbia and Vermont include children's dental benefits.
Senator Debbie Stabenow, Democrat of Michigan, who co-wrote the provision of the law permitting stand-alone dental plans on exchanges, suggested its implementation had fallen short for families like the Barkleys. ''Congress has made clear that the cost of dental care coverage for children, whether through a family's stand-alone dental plan or as part of an overall medical insurance plan, should be included in calculating the amount of tax credit a family receives to help buy affordable insurance,'' she said.
More than a dozen senators and several advocacy groups representing dentists, insurers and consumers have asked the Internal Revenue Service to revisit its decision to deny subsidies to purchasers of stand-alone dental plans for children.
''The lack of a subsidy could have an influence on the purchase of coverage,'' said Evelyn Ireland, the executive director of the National Association of Dental Plans, one such group, adding that ''all of our organizations will push for resolution by early next year.''
Stand-alone dental plans are also exempted from the law's limits on out-of-pocket expenses. While out-of-pocket maximums for health plans are capped at $12,700 per family, stand-alone dental plans may have separate maximums of $700 per child to $1,400 for two or more children. On Dec. 2, the Health and Human Services Department proposed new lower annual limits -- $300 for one child and $400 for two or more -- for all marketplaces in 2015. The public comment period lasts until Dec. 26.
Separate treatment of dental insurance on the exchanges has had another unforeseen consequence: In most states, there's no mandate that parents buy dental insurance for their children at all.
Officials at the Connecticut exchange dodged the problem by requiring all medical plans to provide coverage of children's dental care. ''By embedding it into the plans, we could guarantee it would be purchased,'' said Chad Brooker, policy and legal analyst at Access Health CT.
At least three exchanges -- in Kentucky, Nevada and Washington -- require parents to buy pediatric dental benefits, even if they are sold separately, when buying medical insurance. Without the requirement, the stand-alone dental policies would be less affordable, said Dr. John A. Thompson, a Kentucky dentist on the state exchange board.
''We've spread the risk over a larger population,'' he said, ''and it drives the cost down significantly because not just parents of children with high dental needs are covered.''
But that means that parents who buy medical insurance on the Kentucky exchange might also end up buying a second policy that does not qualify for additional financial supports. Some experts are reluctant to recommend that approach.
''We want to make sure dental coverage is not only essential but affordable,'' said Colin Reusch, the senior policy analyst at the Children's Dental Health Project. ''Given some of the complicating factors, we haven't been convinced yet that we want to require families to purchase.''
Until the new health care law, separate medical and dental plans had been the status quo. Now even some insurers are wondering whether this benefit should be offered separately. Dennis Spain, the chief dental officer of Nevada Dental Benefits, suggested that medical plans might find savings in partnering with dental plans that pay for preventive services.
''Medical plans in Nevada pay for anesthesia for kids who need a massive amount of cavity work in the operating room,'' Mr. Spain said. ''What if I came along and said, 'I'll cut the incidence of early childhood cavities in half'? What's that worth to a medical plan?''
California is revisiting the pediatric dental options on the state exchange in 2015. Some state advocates argue that embedded plans, which would put an end to the medical-dental divide, are the best way forward.
''Kids will have dental care integrated into medical care, and families will have cost sharing the Affordable Care Act is supposed to provide,'' said Kathleen Hamilton, the director of governmental affairs at the Children's Partnership in Sacramento.
''Kids' dental shouldn't be the stepchild of plans the exchanges are offering.''
URL: http://www.nytimes.com/2013/12/17/health/a-gap-in-the-affordable-care-act.html
LOAD-DATE: December 17, 2013
LANGUAGE: ENGLISH
GRAPHIC: PHOTOS: Leilah Barkley's parents are struggling to afford dental insurance for her and her brother, and their government subsidy will not help. (D1)
Top, Blake Barkley and Lisa Wolfe with their children, Leilah and Brayden, outside their home. Above, Leilah played with a pet lizard. Mr. Barkley wanted an insurance plan that covered services like dental cleanings for the children, but found that he would have to buy a stand-alone dental plan. (PHOTOGRAPHS BY EMILY BERL FOR THE NEW YORK TIMES) (D5)
PUBLICATION-TYPE: Newspaper
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The New York Times
March 25, 2016 Friday
Late Edition - Final
Report Offers a Mixed View of Health Care Law Costs
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 882 words
WASHINGTON -- More people will be enrolled in Medicaid than predicted a year ago, fewer will be covered through the new public insurance marketplaces and the overall cost of insurance coverage under the Affordable Care Act will be higher than expected last year, the Congressional Budget Office said Thursday.
But the cost of insuring people will be substantially lower than the budget agency expected when the law was passed, on party-line votes, in 2010. It now estimates that the cost will total $465 billion in 2016-19, which is 25 percent less than its original estimate.
The law slashed the number of uninsured by expanding Medicaid eligibility and by offering subsidies for private insurance sold in the new marketplaces, or exchanges.
Those provisions of the law ''are estimated to reduce the number of uninsured people by 22 million and to result in a net cost to the federal government of $110 billion'' this year, the budget agency said in a new report. The cost of those provisions from 2016 through 2025 is $136 billion higher than projected in last year's report, climbing by 11 percent to a total of more than $1.3 trillion.
Keith Hall, the director of the Congressional Budget Office, said the biggest reason for the changes was an increase in projected spending for Medicaid. More people who qualify for Medicaid under the health care law are expected to enroll, he said.
Projections by the nonpartisan budget office influenced members of Congress who wrote the health law in 2009-10, and its updated estimates continue to shape the debate over health care. Its numbers are used by the White House and by lawmakers of both parties as a benchmark against which to measure the success of the law.
When the law was passed, the budget office predicted that 21 million people would have coverage this year through federal and state insurance exchanges. It reiterated that estimate last March.
Now the budget office says just 12 million people will be covered this year by insurance purchased through the exchanges, and it sees enrollment climbing to 15 million next year and an average of 18 million to 19 million each year from 2018 to 2026.
By contrast, when President Obama signed the health care law, the budget office estimated that 52 million people younger than 65 would have coverage this year through Medicaid or the Children's Health Insurance Program.
It now estimates that an average of 68 million people under 65 will be covered by those programs in a given month this year.
The difference is striking because the budget office's earlier estimate assumed that all states would expand Medicaid. In fact, as a result of a Supreme Court decision, the expansion became optional, and 19 states have refused to participate. The budget office says that 11 million people who became eligible under the Affordable Care Act are now enrolled in Medicaid, and the White House says that another four million uninsured people could gain coverage if all states expanded eligibility.
Medicaid provides more generous, more comprehensive coverage than many of the health insurance policies purchased by consumers on the exchanges.
Major health programs now account for 29 percent of federal spending, according to the budget office, and their share will grow to 32 percent in a decade. If current tax and spending policies remain, it said, the federal budget deficit will total $534 billion this year, nearly $100 billion more than last year. Moreover, it said, ''this year is likely to be the first since 2009 in which the federal deficit will increase as a share of the nation's output -- from 2.5 percent of gross domestic product in 2015 to 2.9 percent in 2016.''
This year, for the first time, the budget office tried to provide a full picture of federal health insurance subsidies for people under 65, and it found that they totaled $660 billion this year.
That includes $32 billion in tax credits to help people pay premiums for insurance on the exchanges; $7 billion in ''cost-sharing reductions,'' which lower their deductibles and other out-of-pocket costs; $64 billion for people who became eligible for Medicaid because of the health law; and $203 billion for people who would have been eligible anyway.
One of the largest subsidies, the budget office said, is a tax break for insurance that people receive through their jobs. What employers pay for such coverage is a form of compensation to employees, but, unlike wages, it is generally not subject to income or payroll taxes. This tax break amounts to a federal subsidy of $266 billion this year, the budget office said.
The report predicts a modest decline in the number of people under 65 with employment-based coverage, to 152 million in 2019, from 155 million today. Most of the change is attributable to the Affordable Care Act, as workers now have other sources of coverage, the budget office said.
It still expects some employers to stop offering coverage, but it acknowledges that ''there is little evidence'' that any substantial number of employers have done so -- a point often made by Obama administration officials in response to critics of the law.
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URL: http://www.nytimes.com/2016/03/25/us/politics/report-offers-a-mixed-view-of-health-care-law-costs.html
LOAD-DATE: March 25, 2016
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The New York Times
December 22, 2013 Sunday
Late Edition - Final
Health Care's Road To Ruin
BYLINE: By ELISABETH ROSENTHAL.
A reporter for The New York Times who is writing a series about the cost of health care, ''Paying Till It Hurts.''
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LENGTH: 1618 words
HAVING spent the last year reporting for a series of articles on the high cost of American medicine, I've heard it all. There was Fred Abrahams, 77, a skier who had surgery on both ankles for arthritis -- one in New York for more than $200,000 and one in New Hampshire for less than $40,000. There was Matthew Landman, 41, billed more than $100,000 for antivenin administered in an E.R. after a small rattlesnake bite. There was Robin Miller, a Florida businessman, who needed to buy an implantable defibrillator for his ill brother, who was uninsured; the machine costs tens of thousands of dollars, but he couldn't get a price for a make or a model.
Extreme anecdotes, perhaps. But the series has prompted more than 10,000 comments of outrage and frustration -- from patients, doctors, politicians, even hospital and insurance executives.
As of Jan. 1, the Affordable Care Act promises for the first time to deliver the possibility of meaningful health insurance to every American. But where does that leave the United States in terms of affordable care?
Even supporters see Obamacare as a first step on a long quest to bring Americans affordable medicine, with further adjustments, interventions and expansions needed.
There are plenty of interesting ideas being floated to help repair the system, many of which are being used in other countries, where health care spending is often about half of that in the United States. For example, we could strictly regulate prices or preset payment levels, as is currently done for hospital stays under Medicare, the national insurance program for people over 65, or at least establish fair price corridors for procedures and drugs. We could require hospitals and doctors to provide price lists and upfront estimates to allow consumers to make better choices. We could stop paying doctors and hospitals for each service they performed and instead compensate them with a fixed monthly fee for taking care of each patient. We could even make medical school free or far cheaper and then require service afterward.
But the nation is fundamentally handicapped in its quest for cheaper health care: All other developed countries rely on a large degree of direct government intervention, negotiation or rate-setting to achieve lower-priced medical treatment for all citizens. That is not politically acceptable here. ''A lot of the complexity of the Affordable Care Act arises from the political need in the U.S. to rely on the private market to provide health care access,'' said Dr. David Blumenthal, a former adviser to President Obama and president of the Commonwealth Fund, a New York-based foundation that focuses on health care.
With that political backdrop, Obamacare deals only indirectly with high prices. By regulating and mandating insurance plans, it seeks to create a better, more competitive market that will make care from doctors and hospitals cheaper. But it primarily relies on a trickle-down theory of cost containment. The Princeton health economist Uwe E. Reinhardt has called it ''a somewhat ugly patch'' on ''a somewhat ugly system.''
With half a billion dollars spent by medical lobbyists each year, according to the Washington-based Center for Responsive Politics, our fragmented profit-driven system is effectively insulated from many of the forces that control spending elsewhere. Even Medicare is not allowed to negotiate drug prices for its tens of millions of beneficiaries, and Americans are forbidden by law to re-import medicines made domestically and sold more cheaply abroad.
And so American patients are stuck with bills and treatment dilemmas that seem increasingly Kafkaesque. The hopeful news is that American health care spending has grown at a slower pace over the past four years. While that is partly because of the recession, economists say, many credit the cost-containing forces unleashed by Obamacare with a significant assist. Even at that rate, many models suggest that nearly 25 percent of gross domestic product will be eaten up by health care in 20 years. That is not sustainable.
''It's like a diet you can't just stop, because it's starting to work,'' said Michael Chernew, an economist at Harvard Medical School. ''And remember, we haven't even lost weight yet, we're just gaining weight more slowly.''
Many health economists say we must move away from the so-called fee-for-service model, where doctors and hospitals bill every event, every pill, every procedure, even hourly rental of the operating room. Though insurers try to hold down costs by negotiating discounts or limiting reimbursement, this strategy has limited power because armies of consultants now advise hospitals on what is known as ''strategic billing'': Losing money from trauma patients? Hospitals can add on a $10,000-plus ''trauma activation fee.'' Medicare not paying enough for a broken wrist? Add a separate ''casting fee'' to the bill.
''People in fee-for-service are very clever -- they stay one step ahead of the formulas to maximize revenue,'' said Dr. Steven Schroeder, a professor at the medical school of the University of California, San Francisco.
Given that national or even regional rate-setting is out of the question, most health economists argue that the nation needs a new type of payment model, one where doctors and hospitals earn more by keeping patients healthy with preventive care rather than by prescribing expensive tests.
Such models exist: A number of hospital and doctors groups engage in so-called capitated care, where they are paid an annual fee by an employer or individual for all patient needs and must work within that budget. The Affordable Care Act promotes a strategy focused on accountable care organizations, in which similar networks can earn financial rewards for figuring out how to save money while meeting standards for good care. But such models are still far from the norm in a country where a majority of physicians are in business for themselves and doctors and hospitals bill separately.
The new law includes a number of incentives intended to nudge doctors, hospitals and insurers to join groups and focus more on value, ''but we don't know how well they're going to work,'' said John Holahan, a fellow at the Urban Institute's Health Policy Center.
For example, the law will tax premiums for the most expensive insurance plans to keep luxury health care spending down. And Medicare, through a value-based purchasing program set up by the law, is providing bonuses to doctors and hospitals for meeting quality-care standards. But those are tentative steps. In fact, recent research published in the journal Health Affairs concluded that the magnitude of bonuses now offered to hospitals was too small to change behavior, noting that even supermarket coupons tended to offer benefits worth well over 10 percent of total value.
The Affordable Care Act generally requires patients to be responsible for more of their bills -- copays and deductibles -- so they will become more price-savvy medical consumers. But the deck is stacked against them in a system where doctors and hospitals are not required or expected to provide upfront pricing. Why not? They should tell and patients should ask. (In France, before a hip replacement on a private patient, doctors must sign a contract that includes a price.)
And policy makers need to address two of the biggest drivers of our inflated national health care bill: the astronomical price of hospitalizations and particularly end-of-life care.
Obamacare plans cap an individual's annual out-of-pocket spending at $6,350 a year. That (happily) prevents bankruptcy, but it also means that patients will still not be very discerning shoppers when it comes to major hospitalizations, since -- in the United States -- they've quite likely surpassed their out of pocket maximum by the time they've been formally admitted.
On the private side, some companies and employee health plans are experimenting with new payment models to limit these large bills. They may follow Medicare, which offers hospitals bundled payments for given procedures, or try a technique known as reference pricing, in which they pick a rate they think is fair for a procedure -- say $32,000 for a knee replacement, all-inclusive. If a patient wants to go to a hospital with higher fees, the difference comes out of his pocket.
To rein in price increases, companies and insurers have begun offering patients narrower networks, already a major gripe about many Obamacare plans.
And as choices narrow while prices rise, I sense that many patients are no longer so devoted to a market-based health care system. Barbara Felton, 86, was ''shocked'' when she saw her $12,000 itemized hospital bill for a recent brief stay to repair a fractured femur in Pocatello, Idaho. ''I've never been in favor of a single payer before, but now I am,'' she said, referring to a government-run health system.
The perfect recipe for containing medical costs remains to be written and must be tweaked thoughtfully. After all, the American health care system is a major part of the economy. As Dr. Blumenthal, the former Obama adviser, put it: ''If you put our health care system on an island and floated it out into the Atlantic it would have the fifth-largest G.D.P. in the world. It's like saying you have to change the economy of France.''
But after a year spent hearing from hundreds of patients like Mr. Abrahams, Mr. Landman and Mr. Miller, I know, too, that reforming the nation's $2.9 trillion health system is urgent, and will not be accomplished with delicate maneuvers at the margins. There are many further interventions that we know will help contain costs and rein in prices. And we'd better start making choices fast.
URL: http://www.nytimes.com/2013/12/22/sunday-review/health-cares-road-to-ruin.html
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The New York Times
September 11, 2015 Friday
Late Edition - Final
House Stretches Legal Logic on Health Reform
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 28
LENGTH: 525 words
Once again congressional Republicans are trying to manipulate the courts into overturning health care reforms that they have been unable to block in the normal political process.
Conservative lawyers backed by Republicans got a well-deserved rebuke in June when the Supreme Court ruled that people in every state are eligible for tax-credit subsidies to help them buy insurance on new exchanges, regardless of whether the exchanges are set up by the state or the federal government.
This week, however, House Republicans got a court to allow them to move forward on a baseless lawsuit they filed to block subsidies that keep deductibles and co-payments low for more than five million low-income people. The Affordable Care Act requires insurance companies to reduce cost-sharing for people buying health care on exchanges based on their incomes, with the federal government reimbursing the insurers for the cost.
The suit was filed last November by the Republican-dominated House, which argued that the Obama administration had violated the Constitution by providing cost-sharing subsidies that Congress had never specifically approved. It seeks to stop the administration from distributing some $136 billion to the insurers over a decade.
The administration contends that it has the authority under the reform law to distribute the money without getting a specific annual appropriation, and that it is simply carrying out the law.
Before the suit could proceed, the House had to show that it had standing to sue. Many legal experts argued that the plaintiffs could not meet that requirement, since the House is only one chamber, not the entire Congress, and that courts are reluctant to intervene in political battles between branches of government.
Judge Rosemary Collyer of the United States District Court, who was appointed by President George W. Bush, however, ruled on Wednesday that the House could proceed despite those objections.
She said that the House was sufficiently affected to have standing to sue, even without the Senate joining in. And she said the lawsuit was the only way for the House to preserve its constitutional power to control federal spending. The White House said it would appeal the decision and expected the courts to dismiss it.
The judge said she was not ruling on the merits of the case, which she will determine in a later proceeding. In truth, this lawsuit seems to be an effort to get around a legislative defeat -- basically a typical, garden-variety political dispute -- that has no business being in the court system. If the Republicans want to end all cost-sharing subsidies, they could make that explicit by rewriting the health reform law.
A few years ago Jack Balkin, a Yale Law School professor, described how ''off-the-wall'' legal arguments, which most mainstream lawyers think clearly violate legal precedents, have been taken up and legitimized by judges sympathetic to them. It would be a travesty if this lawsuit ends up creating the same havoc as other baseless challenges to the Affordable Care Act, which took up enormous resources and time, only to be struck down by the Supreme Court.
URL: http://www.nytimes.com/2015/09/11/opinion/the-house-stretches-legal-logic-on-health-reform.html
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The New York Times
March 3, 2017 Friday
Late Edition - Final
G.O.P. Accused of Playing Health Act 'Hide-and-Seek'
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 1101 words
WASHINGTON -- It was ''find the Affordable Care Act replacement'' day on Thursday as publicity-seeking Democrats -- and one frustrated Republican -- scampered through Capitol corridors, hunting for an elusive copy of a bill that Republican leaders have withheld from the public as they search for party unity.
Just a week before two powerful House committees plan to vote on the measure, opponents spent hours making the point that almost no one has actually seen legislation that would affect the lives and pocketbooks of millions of Americans.
''The Republicans have played hide-and-seek with us,'' said Representative Lloyd Doggett, Democrat of Texas.
Speaker Paul D. Ryan of Wisconsin said party leaders were determined to plow ahead with repeal legislation, despite lingering disagreements among Republicans and outright opposition from Democrats.
''I am perfectly confident that when it's all said and done, we're going to unify, because we all, every Republican, ran on repealing and replacing, and we're going to keep our promises,'' Mr. Ryan said.
The Energy and Commerce Committee, which has jurisdiction over Medicaid, and the Ways and Means Committee, which is responsible for tax legislation, are tentatively scheduled to vote next week on the repeal bill, setting the stage for the full House to vote on it later this month, House Republican leaders said.
While Republicans discussed details of the health care bill, Democrats went from office to office, hunting for a copy. Lawmakers were told that Republican members of the Energy and Commerce Committee could inspect the bill on Thursday in the basement of a House office building. When Democrats arrived, they were directed to a room on the first floor of the Capitol.
The House Democratic whip, Representative Steny H. Hoyer of Maryland, and Representative Paul Tonko, Democrat of New York, went to that room, but could not find the bill there.
Senator Rand Paul, a Kentucky Republican who has criticized the repeal bill, also tried and failed to see it.
''I have been told that the House Obamacare bill is under lock & key, in a secure location, & not available for me or the public to view,'' Mr. Paul said on Twitter as he set off in search of the document, carrying a portable copy machine and trailed by television cameras and a pack of journalists.
Mr. Paul supports repealing the Affordable Care Act, but said the measure described publicly by House Republican leaders included ''Democratic ideas dressed up in Republican clothing.''
Mr. Hoyer, whose quest for the bill was broadcast live on Facebook, paused to address a large bust of Abraham Lincoln. ''I can't find the bill,'' he said, adding, ''I know, Mr. Lincoln, you are as upset with your party as I am today.''
The theatrics reflected serious concerns. ''Republicans are hiding their draft A.C.A. repeal bill in a basement room,'' said the House Democratic leader, Nancy Pelosi of California. The bill, she said, would produce ''a big transfer of wealth to the wealthiest people in our country,'' cutting their taxes while increasing costs for others.
It is not unusual for controversial bills to be written by the majority party, with little or no input from the minority. But Democrats relished the opportunity to turn the tables on Republicans.
In 2009 and 2010, Republicans excoriated Democrats for making ''back-room deals'' to pass the Affordable Care Act. Democrats, defending the bill they had written with President Barack Obama, were shouted down at town hall-style meetings by Tea Party members chanting, ''Read the bill.''
Representative Greg Walden, Republican of Oregon and chairman of the Energy and Commerce Committee, denied he was hiding the bill or doing anything out of the ordinary. Republicans, he said, ''are continuing to discuss and refine draft legislative language.''
Asked if he was hiding the bill, Representative Kevin Brady, Republican of Texas and chairman of the Ways and Means Committee, said: ''We don't have a bill. We're continuing to work with the Congressional Budget Office and our members on the final product.''
Republicans had promised an open process. Speaking on the House floor on Jan. 13, Representative Doug Collins of Georgia, the vice chairman of the House Republican Conference, said the health law had been enacted ''after months of back-room deals, in the middle of the night, last-minute deals, and without giving the American people enough time to even read the bill.''
''That is not what is going to happen this time,'' he said.
The Congressional Budget Office has not completed an estimate of the cost of the repeal bill or its effects on coverage, and Republicans are still trying to narrow their differences on issues like Medicaid and tax credits to help people buy insurance. But, as of Thursday, they were determined to move ahead.
''We are going to mark up the legislation next week,'' said Representative Billy Long, Republican of Missouri and a member of the Energy and Commerce Committee, after a closed-door meeting of House Republicans. ''They say we'll be there all night. I'm going to bring an air mattress.''
Mr. Ryan presented members of his party on Thursday with a timeline leading to passage of the bill by the House within three weeks. The Senate is working closely with House leaders.
Mr. Ryan told House Republicans that President Trump supported the bill drafted by House Republican leaders, according to aides who were in the room.
Ever since Mr. Obama signed the law in March 2010, Republicans have been trying to uproot it. When Congress convened this year, Republicans thought they could achieve their goal with a quick strike on the law, which has provided insurance to some 20 million Americans. The task has proved more difficult than they expected. Polls show the law has become somewhat more popular as Mr. Trump and congressional Republicans try to kill it.
Under a draft of the bill that became public last week, the government would offer tax credits to help lower the cost of insurance for people who did not have access to coverage through an employer or a government program. The tax credits, as initially proposed, would be available to people regardless of their income.
Representative Phil Roe, Republican of Tennessee, said the credit should not be available to people with incomes above a certain level, around $118,000. ''I don't think I need a tax credit, with my salary,'' Mr. Roe said. As a member of Congress, he has been paid $174,000 a year.
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URL: http://www.nytimes.com/2017/03/02/us/politics/obamacare-aca-repeal-replace.html
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The New York Times
August 28, 2013 Wednesday
Late Edition - Final
Michigan Passes Bill To Expand Medicaid
BYLINE: By MONICA DAVEY
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 872 words
CHICAGO -- The fierce struggle among Republicans over whether to make Medicaid available to more low-income people played out in Michigan on Tuesday as the Republican governor, Rick Snyder, narrowly succeeded in swaying enough conservative senators in the State Legislature to accept the expansion, which was part of President Obama's health care law.
Mr. Snyder's preferred bill -- one he had lobbied for intensely for months -- initially fell short by one vote, but the governor salvaged a deal hours later. The vote in the Republican-controlled Senate was 20 to 18, with only 8 Republicans in favor. The Michigan House, which had earlier approved a similar measure, will need to vote on the Senate version before Mr. Snyder can sign the bill.
''The Affordable Care Act has probably been one of the most divisive issues that our country has faced in the last few years, and many people do have strong opinions both for and against,'' Mr. Snyder said after the vote. ''I just ask that all Michiganders step back and look to say this isn't about the Affordable Care Act. This is about one element that we control here in Michigan that we can make a difference in here in people's lives.''
While the authors of the federal health care law intended to expand Medicaid, the federal and state health program for poor people, and at least initially pay for the expansion, the Supreme Court ruled in 2012 that states could opt out, setting up a struggle that has played out in the states largely along partisan lines.
Like Mr. Snyder, some Republican governors have found themselves at odds with their own party's legislative caucuses in state capitals like Lansing that are dominated by Republicans.
In Arizona, which eventually approved an expansion, Gov. Jan Brewer found vehement opposition from some lawmakers. In Florida, legislators have resisted expansion, despite Gov. Rick Scott's support. And in Ohio, Gov. John R. Kasich's push for expansion has so far not been successful.
For months, the fight in Michigan, which has the nation's 10-largest uninsured population, has been intense. Mr. Snyder, a former businessman in his first term, said the expansion would ultimately save money, control medical costs and help the state's economy. That pitted him against more conservative members of his own party, and led some Tea Party leaders in the state to say he will lose support if he seeks re-election next year.
On the floor of the Michigan Senate on Tuesday, the debate was heated, though lawmakers said the discussions -- particularly those within the Republican caucus -- had been even more tense behind closed doors.
Advocates praised the measure as fiscally sensible for the state, given the promise of federal money, and crucial for hundreds of thousands of low-income residents without insurance.
Already, Medicaid covers more than 1.8 million people in the state, Michigan officials said, and the expansion would ultimately grant coverage to more than 400,000 others. People making up to 133 percent of the federal poverty level -- or about $15,500 a year for a single person -- would newly be covered.
''It's a benefit to every person in the state of Michigan,'' said State Senator Gretchen Whitmer, the Democratic leader, said on the floor. ''It's good public policy, and it makes good fiscal sense.''
Senator Roger Kahn, a Republican, told his colleagues, ''This is not Obamacare or the Affordable Care Act.'' Instead, he argued, the measure will reform the costs of medicine across the state and become what he described as ''a national model'' for other states.
But opponents said a Medicaid expansion would represent tacit approval of Mr. Obama's health care law. They said it would encourage big government and be an irresponsible promise of spending by Michigan in the years ahead. Senator Mike Green, a Republican, described the plan as a promise of ''federal funny money.''
And Senator Patrick J. Colbeck, another Republican opponent, said, ''We're spending money we do not have,'' adding, ''And we're forcing decisions right now onto our youth.''
In June, the Michigan House approved the Medicaid expansion with support from Democrats and enough members from that chamber's Republican majority. But the State Senate, where Republicans hold 26 of 38 seats, moved more slowly, with some conservative Republicans openly rejecting Mr. Snyder's views, refusing to call a vote and proposing alternatives.
At one point, Mr. Snyder, who regularly promotes a gentle-sounding political philosophy of ''relentless positive action,'' flew home early from a trade mission to Israel and had uncharacteristically sharp words for the Senate, telling them to ''take a vote, not a vacation.''
In recent days, the struggle intensified. The governor's office took part in urgent, private conversations, lawmakers said, while advocates for and against the measure led demonstrations, ad campaigns and phone banks around Michigan.
''We firmly believe that a vote to support Medicaid expansion is a vote to support the president's health care law,'' said one opponent, Annie Patnaude, deputy state director of Americans for Prosperity-Michigan. Protesters on the other side of the issue appeared in Lansing on Tuesday, saying it was high time for a vote.
URL: http://www.nytimes.com/2013/08/28/us/medicaid-expansion-battle-in-michigan-ends-in-passage.html
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GRAPHIC: PHOTO: Gov. Rick Snyder of Michigan, flanked last month by officials of a hospital in Royal Oak, promoted his Medicaid plan. (PHOTOGRAPH BY CARLOS OSORIO/ASSOCIATED PRESS) (A19)
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September 5, 2013 Thursday
Hi, It's Your Doctor
BYLINE: EZEKIEL J. EMANUEL
SECTION: OPINION
LENGTH: 909 words
HIGHLIGHT: After a half-century, the doctor’s house call is making a comeback.
MY father, a pediatrician, kept all his medical equipment in a black leather bag. He used to take it on house calls. My brothers and I would frequently tag along to watch him treat patients. He would remove stitches from over an eye or look into a throat and ears, providing a few pills to start a regimen of antibiotics for an ear infection.
Sometime in the late 1960s, he stopped making house calls. Instead, my father began routinely sending patients to the hospital emergency room.
And he wasn't alone. In 1930, house calls accounted for 40 percent of physician interactions. By 1980, that number had dropped to 1 percent.
But after a half-century, the house call is making a comeback. The available data on house calls are spotty at best. But one study estimated that in 2010, about 4,000 physicians conducted more than two million house calls. Some do what my father did: attend to urgent but not emergency situations, taking care of people with stomach pain, fever, cuts needing stitches and the like. These kinds of urgent-care problems are best treated by a house call, but account for about 40 percent of the nearly 130 million annual visits to emergency rooms.
Companies like Microsoft and Costco provide similar house calls to their employees in the Seattle area. Carena, a private company under contract for the service, sends out doctors or nurse practitioners to assess the situation with the assistance of computer software. The software uses algorithms to help them differentiate between cases that are safe to handle at home and those that require the emergency room.
In addition to dealing with urgent matters, the house calls let providers teach patients how to deal with chronic problems they might have, like diets for diabetics, care that is always easier in the privacy of a home. The cost is around $500 a visit, which may be covered by their employer's health plan. Beginning in 2010, Carena began offering "virtual" house calls, allowing people to use a webcam to get medical attention. Those calls are available to both employees of companies and, increasingly, individuals who aren't employees but who are willing to pay the $85 cost per call, less than the hundreds of dollars it would take to have a rash seen at an emergency room. According to Carena, about 75 percent of those calls are resolved via the webcam, and only 25 percent require an in-person visit with a doctor or a trip to the emergency room.
Other house calls are more like office visits, but done at home, often for frail older patients. Many of those people suffer from multiple diseases - heart conditions, emphysema, diabetes, arthritis, dementia - that make getting to the doctor's office difficult. And those are the people whose care is often billed to Medicare, so if they don't see health care professionals regularly, their next stop could easily be the emergency room and a hospitalization. The Department of Veterans Affairs has pioneered this kind of house call.
The Affordable Care Act began financing a project in 2012 to determine in what setting house calls can be most effective. Doctors who make house calls share in savings if they provide quality care and reduce costs.
There are small studies that indicate these primary care visits can decrease hospitalization rates by more than 60 percent and save around 25 percent in total costs - all with extremely high patient satisfaction.
A third kind of house call is really an extension of the hospital. Transitions from hospitals are fraught with problems - patients not taking medications or following doctors' instructions - and around 20 percent of Medicare patients are readmitted within 30 days of discharge. But hospitals have had little incentive to provide care in the home after treatment because they make money from the readmissions. The Affordable Care Act now imposes penalties on hospitals that have high readmission rates for conditions like heart failure and pneumonia. To avoid the penalties, hospitals are increasingly deploying nurses on these types of house calls.
Finally there is what is called Hospital at Home. Begun at Johns Hopkins in Baltimore, this program takes patients who would otherwise be admitted to a hospital for conditions like urinary and skin infections, pneumonia and heart failure, and instead sets up hospital-type services in the patient's home. Intravenous antibiotics, oxygen, breathing treatments, even diagnostic tests like EKGs and X-rays are done at home. Physicians visit patients each day. Nurses visit once or twice a day, and monitor the patients remotely.
Studies show that patients treated at home do just as well in terms of recovery as patients admitted to the hospital, and maybe even better when it comes to how quickly they get better and how well they avoid common complications. And they save money. In a study in New Mexico involving more than 500 patients, there was a 19 percent cost savings. In a study at the University of Pennsylvania and at the Veterans Affairs medical center in Philadelphia, there was a 43 percent savings.
So fire up your DeLorean. Health care is headed back to the future. House calls are a sign that we will all see our health care going back to the "old days" when, like my father, the doctor came to our homes, giving us real personalized medicine - and saving money at the same time.
Healing the Hospital Hierarchy
Don't Get Sick in July
Forgetting Grandma
When No One Is on Call
The Cure for the $1,000 Toothbrush
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The New York Times
March 23, 2017 Thursday
Late Edition - Final
Leaders Struggle to Unite House Republicans Behind Health Bill Before Vote
BYLINE: By ROBERT PEAR and THOMAS KAPLAN; Emmarie Huetteman and Jeremy W. Peters contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1175 words
WASHINGTON -- The House bill to repeal the Affordable Care Act faced an uncertain fate on Wednesday as conservative Republicans pushed to eliminate federal requirements that health insurance plans provide certain benefits to consumers.
House Republican leaders met with members of their party late into the night on Wednesday as they struggled to muster support for the bill, scheduled for a vote on the House floor on Thursday.
President Trump, Vice President Mike Pence and the House speaker, Paul D. Ryan of Wisconsin, worked through the day to placate conservative House Republicans who said that the bill did not do enough to lower health insurance costs by reducing federal regulations. The legislation would roll back major provisions of the Affordable Care Act, a major pillar of President Barack Obama's legacy.
But in trying to satisfy conservatives, the Trump administration and House Republican leaders risked jeopardizing support for the bill among more moderate Republicans. On the eve of the crucial vote, party leaders appeared to be short of a majority and were working into the night to whip their members into line.
Representative Mark Meadows, Republican of North Carolina and the chairman of the conservative House Freedom Caucus, expressed optimism on Wednesday night that talks with Republican leaders would lead to revisions to the bill.
''We're encouraged tonight, just based on the real willingness of not only the White House, but our leadership, to make this bill better,'' Mr. Meadows said, crediting the personal involvement of Mr. Trump and Mr. Pence.
But Representative Charlie Dent, Republican of Pennsylvania and a leader of a moderate bloc of lawmakers known as the Tuesday Group, said late Wednesday night that he would oppose the bill.
''I believe this bill, in its current form, will lead to the loss of coverage and make insurance unaffordable for too many Americans, particularly for low-to-moderate income and older individuals,'' Mr. Dent said.
And the powerful conservative network funded by the billionaire brothers Charles and David Koch issued a direct challenge to the president and said that it would provide financial support to members who voted against the plan.
''We will stand with lawmakers who keep their promise and oppose this legislation,'' said James Davis, executive vice president of Freedom Partners, the umbrella organization responsible for the Koch brothers' political efforts.
About two dozen conservative Republicans, including Freedom Caucus members, met Wednesday at the White House with top administration officials, including Mr. Pence and Kellyanne Conway, a senior adviser to Mr. Trump.
''I don't think they changed any minds,'' Representative Randy Weber, Republican of Texas, said after the meeting.
The tenacity and persistence of the conservatives appeared to give them outsize influence as Mr. Ryan struggled to round up votes for the repeal bill, which faces solid opposition from House Democrats. Supporters of their bill have put their faith in Mr. Trump, whose young presidency could be badly damaged by a public and consequential loss.
''When the president calls someone and says, 'I need your vote on this,' it's very hard to say no to the president of the United States when this torpedoes our entire conference, Trump's entire presidency, and we end up losing the Senate next year and we lose members in the House,'' said Representative Chris Collins, Republican of New York and a top Trump supporter in the House.
But conservative opposition was over substance, not politics. Conservatives are upset over the failure of the House bill to repeal a set of regulations in Mr. Obama's signature health law, which require insurers to cover a base set of benefits, like maternity care, preventive services, wellness checkups and rehabilitative services. These ''essential health benefits'' raise the cost of insurance and prevent companies from offering stripped-down options, the conservatives say.
''How can you talk about repealing the Affordable Care Act, Obamacare, without repealing the essential health benefits?'' asked Representative Scott Perry, a Pennsylvania Republican who attended the meeting with Mr. Pence.
Republican leaders say that if the House makes such changes to the bill, it could imperil their ability to push the legislation through the Senate using expedited procedures that neutralize the threat of a filibuster.
Representative Mike Simpson, Republican of Idaho, likened the swirling cloud of uncertainty to the situation in November 2003, when the House approved a bill adding prescription drug benefits to Medicare after a roll-call vote that lasted nearly three hours in the middle of the night. The bill passed, 220 to 215, after House Republican leaders put down a conservative rebellion.
''It's tough to pass controversial things, especially when Republicans have different ideas,'' Mr. Simpson said. Eventually, he predicted, House leaders will get the votes they need, though they may need to tweak the repeal bill.
Representative Scott DesJarlais, Republican of Tennessee, said the administration tried to sell the House bill, known as the American Health Care Act, by arguing that it could be improved later in the Senate. But House members rarely relish handing their political fate to the other chamber.
''I am more skeptical,'' Mr. DesJarlais said. ''I like to see what I'm going to get when I vote for it, not promises that I get later.''
Asked if supporters of the bill had the votes to pass it in the House, Mr. DesJarlais said, ''I don't think they do.''
A spokeswoman for the Freedom Caucus, Alyssa Farah, said that more than 25 members of the caucus were ''no'' votes on the health care measure -- enough to sink the bill in the House, though that count could not be independently verified.
Representative Andy Harris, Republican of Maryland, said that despite recent changes to the health care bill, he was unable to vote for it.
''This legislation simply won't lower premiums as much as the American people need, and lowering the cost of coverage is my primary goal,'' said Mr. Harris, an anesthesiologist and member of the Freedom Caucus.
House leaders were also contending with opposition from more moderate Republicans worried about the toll that the health bill could take in their districts. Representative Dan Donovan of New York, who attended a meeting at the White House with Mr. Trump on Tuesday, said Wednesday that he would vote against the bill.
''Recognizing that the status quo is failing isn't, on its own, a compelling reason to vote 'yes' on the current replacement plan,'' said Mr. Donovan, the only Republican House member from New York City.
Sean Spicer, the White House press secretary, said he was sure the House would pass the repeal bill. ''Slowly but surely we're getting there,'' he said. ''There is no Plan B. There's Plan A and Plan A. We're going to get this done.''
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URL: http://www.nytimes.com/2017/03/22/us/politics/health-care-vote-republicans.html
LOAD-DATE: March 23, 2017
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GRAPHIC: PHOTO: Representative Jim Jordan of the House Freedom Caucus. More than 25 of its members were said to oppose the bill. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES)
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November 26, 2016 Saturday
Late Edition - Final
Where Trump Won, Many Want to Keep Health Care
BYLINE: By ABBY GOODNOUGH; Robert Pear contributed reporting from Washington.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1580 words
MIAMI -- Dalia Carmeli, who drives a trolley in downtown Miami, voted for Donald J. Trump on Election Day. A week later, she stopped in to see the enrollment counselor who will help her sign up for another year of health insurance under the Affordable Care Act.
''I hope it still stays the same,'' said Ms. Carmeli, 64, who has Crohn's disease and relies on her insurance to cover frequent doctor's appointments and an array of medications.
Mr. Trump and Republicans in Congress are vowing to repeal much or all of the health law, a target of their party's contempt since the day it passed with only Democratic votes in 2010. If they succeed, they will set in motion an extraordinary dismantling of a major social program in the United States.
But for now, with open enrollment for 2017 underway, people are steadily signing up or renewing their coverage, and in conversations last week in South Florida, many refused to believe that a benefit they count on would actually be taken away.
Florida helped hand Mr. Trump the presidency when he narrowly won the state, but it has also provided more customers for the federal health insurance marketplace than any other state. This makes Florida a window to the complex and delicate task Mr. Trump and congressional Republicans face in deciding whether to scrap the entire law, which has brought coverage to more than 20 million people, and what to replace it with.
Even though Gov. Rick Scott fiercely opposes the law, more than 1.5 million Floridians were enrolled in marketplace plans as of March, the last time the Obama administration released data. And some of the problems that have plagued the marketplaces in other states have been less of an issue here: The premium increases and overall prices have been lower than average, and at least in urban areas, a number of insurers are still participating.
Jay Wolfson, a professor of public health and medicine at the University of South Florida, said that while many Floridians would be happy to see the law disappear, and the state's Republican leaders have never shied away from attacking it, failing to come up with a substantive replacement could be politically risky.
''The question I think we all have is, how do they transition out of it?'' he said. ''How do they do it without dumping millions of people off the edge of a cliff?''
Despite the law's problems, including sharp premium increases for next year, millions of people, including many in states that Mr. Trump won, have come to depend on it. Texas, North Carolina and Georgia, like Florida, have large numbers of people insured through HealthCare.gov. And 16 states that now have Republican governors or governors-elect expanded Medicaid under the law, including Indiana under Mike Pence, now the vice president-elect.
The Obama administration said last week that over the first 12 days of open enrollment, plan selections in the states that use the federal marketplace were up by about 5 percent compared with the same period last year. Some of the states that run their own marketplaces have reported brisker business: In Colorado, sign-ups are running 30 percent higher than they were at this point in the last open enrollment period, according to Kevin Patterson, the chief executive of the state's marketplace.
If the pace continues, hundreds of thousands more people could be added to the insurance rolls, even as Republicans discuss alternative legislation that could drop millions.
''Even with the whole situation, it's been a great start,'' said Odalys Arevalo, an owner of Sunshine Life and Health Advisors, an insurance agency that she said has enrolled tens of thousands of Floridians, mostly working-class Hispanics, in health law plans over the past three years. She added, however, that people were confused and were asking many questions about the future of the law.
Nonprofit groups with federal grants to enroll the uninsured are conducting an ever more strategic search for them -- working, for example, with the consulates of Mexico, Colombia, Brazil and Uruguay in Miami to identify ''lawfully present'' immigrants who might want coverage (they qualify for subsidies under the law, even without citizenship) and with a small American Indian tribe in the Panhandle.
''We're in the here and now, and nothing has changed at the moment,'' said Karen Egozi, the chief executive of the Epilepsy Foundation of Florida, repeating a new mantra among the group's 90 enrollment counselors. As of Tuesday, they had signed up 277 people for insurance since Nov. 1, when enrollment began, she said, compared with 193 over the same period last year.
In South Florida, a teeming mix of retirees who may not have reached Medicare age, hotel and restaurant workers and recently arrived immigrants working for small, homegrown businesses has helped ensure robust enrollment in the subsidized plans offered through the marketplace. While the Republican leaders of the state have refused to expand Medicaid, individuals with annual incomes of about $12,000 to $47,500 qualify for subsidies that pay some or most of the cost.
Ninety-one percent of plan holders in Florida this year receive premium subsidies -- a higher percentage than in any other state -- and 71 percent also have reduced deductibles, a benefit available to people at or below 250 percent of the poverty level.
Some of them, like Ms. Carmeli, voted for Mr. Trump. She pays $45 toward her monthly premium, with a subsidy of about $600 covering the rest. She is looking at a new premium of $171 if she keeps her current plan, but she believes that she will find a more affordable option.
''Trump is going to keep it for a while, at least the part where if you have a disease you can still get coverage,'' she said, adding that she would turn 65 next summer and get Medicare, so she would stay covered regardless.
More vulnerable are people like Gerardo Murillo Lovo, 44, a construction worker who never had health insurance before signing up for a marketplace plan in 2014. He pays $15 a month and gets a subsidy of $590 for a plan that covers his wife, as well. When he renewed his coverage last week at the Epilepsy Foundation, he learned that the price would not increase next year.
''I've heard that what he wanted to do first is get rid of Obamacare,'' Mr. Murillo, a Nicaraguan immigrant who is a citizen but did not vote, said of Mr. Trump. ''But my personal opinion is that he will discuss it with other people who will convince him that we can't get rid of this. I think it's going to be maintained one way or another, and I'm going to keep it as long as I can.''
Mr. Trump has suggested he would like to keep popular parts of the law that guarantee access to insurance for people with pre-existing conditions and that allow children to stay on their parents' policies until they turn 26. Congressional Republicans have floated other ideas, like providing tax credits to people who buy their own health insurance, but have not yet unified around a replacement plan. The challenge they face, health care economists say, is keeping prices down without requiring everyone to have coverage, the way the Affordable Care Act does.
Even the possibility of repeal is causing extreme anxiety among some people with health problems. Mary Benner, 57, who lives near Tampa and voted for Hillary Clinton, will undergo a test next week to determine whether a spot on her lung, discovered on a routine X-ray, is cancer.
''This has been a nightmare for me,'' she said of having a health scare just as Mr. Trump won the presidency and renewed his promise to repeal the law. ''What I'm really hoping is that they won't be able to come to an agreement and can't get anything passed, so everything just stays the same.''
Others, particularly those with higher incomes, are re-enrolling grudgingly, soured by the increasingly expensive cost of marketplace plans. Bob Verrastro, a corporate tax consultant who voted for Mr. Trump, said that while he and his wife get a subsidy that reduces their monthly premium to $274, their deductible and other out-of-pocket costs are unaffordable, and he is eager to see the law repealed.
''I think it was rammed down our throats,'' Mr. Verrastro, 64, of Boynton Beach, said of the law. ''I'm taking advantage of it because I'd be silly not to. But it needs to be changed.''
Luis Perez Cuevas last week visited a kiosk run by Sunshine Life and Health Advisors in the Mall of the Americas in Miami, ready to renew his marketplace plan. First, though, he asked his agent, Dennis Garcia, whether it would be foolish to do so.
''I actually believe Trump's rhetoric,'' said Mr. Perez, 55, an Uber driver and maintenance worker at the Miami Beach Convention Center.
Mr. Perez is paying $107 a month for his plan this year, but next year the price will drop to $49 a month, with a $484 subsidy, in part because his daughter came from Cuba and joined his household as a dependent. Because his income is low, the government also covers his deductible.
After Mr. Perez left, Mr. Garcia, the insurance agent, allowed that he hoped Mr. Trump would, in fact, change the law. It is not fair that low-income people get help with their deductibles, he said, while marketplace customers with slightly higher incomes, like himself, do not.
''Maybe Mr. Trump can make it better by making it more equal,'' he said.
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URL: http://www.nytimes.com/2016/11/25/health/florida-affordable-care-act-obamacare-trump.html
LOAD-DATE: November 26, 2016
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: Customers in Miami with an insurance agent for Sunshine Life and Health Advisors, which has enrolled tens of thousands of Floridians under the Affordable Care Act over the past three years. (PHOTOGRAPH BY ANGEL VALENTIN FOR THE NEW YORK TIMES) (A11)
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The New York Times
May 14, 2016 Saturday 00:00 EST
Sorry, We Don't Take Obamacare;
News Analysis
BYLINE: ELISABETH ROSENTHAL
SECTION: SUNDAY-REVIEW
LENGTH: 1757 words
HIGHLIGHT: The growing pains of the health care act are frustrating patients.
AMY MOSES and her circle of self-employed small-business owners were supporters of President Obama and the Affordable Care Act. They bought policies on the newly created New York State exchange. But when they called doctors and hospitals in Manhattan to schedule appointments, they were dismayed to be turned away again and again with a common refrain: "We don't take Obamacare," the umbrella epithet for the hundreds of plans offered through the president's signature health legislation.
"Anyone who is on these plans knows it's a two-tiered system," said Ms. Moses, describing the emotional sting of those words to a successful entrepreneur.
"Anytime one of us needs a doctor," she continued, "we send out an alert: 'Does anyone have anyone on an exchange plan that does mammography or colonoscopy? Who takes our insurance?' It's really a problem."
The goal of the Affordable Care Act, which took effect in 2013, was to provide insurance to tens of millions of uninsured or under-insured Americans, through online state and federal marketplaces offering an array of policies. By many measures, the law has been a success: The number of uninsured Americans has dropped by about half, with 20 million more people gaining coverage. It has also created a host of new policies for self-employed people like Ms. Moses, who previously had insurance but whose old plans were no longer offered.
Yet even as many beneficiaries acknowledge that they might not have insurance today without the law, there remains a strong undercurrent of discontent. Though their insurance cards look the same as everyone else's - with names like Liberty and Freedom from insurers like Anthem or United Health - the plans are often very different from those provided to most Americans by their employers. Many say they feel as if they have become second-class patients.
This disappointment is fueling renewed interest in a "public option" that would supplement current offerings. That idea found support from both Senator Bernie Sanders and Hillary Clinton as the Affordable Care Act was making its way through Congress. It was taken up again last week by Mrs. Clinton, when she suggested allowing people 55 and over to buy into Medicare, the government-run insurance for people 65 and over, which is accepted by virtually all hospitals.
Some early studies of the impact of the Affordable Care Act plans are proving patients' grumbling justified: Compared with the insurance that companies offer their employees, plans provide less coverage away from patients' home states, require higher patient outlays for medicines and include a more limited number of doctors and hospitals, referred to as a narrow network policy. And while employers tend to offer their workers at least one plan that allows them coverage to visit doctors not in their network, patients buying insurance through A.C.A. exchanges in some states do not have that option, even if they're willing to pay higher premiums.
Many of the problems may well be the growing pains of a young, evolving system, which established only broad standards for A.C.A. plans and allowed insurers - a large majority of them for-profit - considerable leeway in designing their exact offerings. The specific requirements and policing mechanisms vary by state, and are still works in progress.
Daniel Polsky, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, is among the researchers who have been studying the law's effects on patients' access to care. "We hear lots of complaints, but we really don't know the extent of the problem because there's still very little data," he said.
The legislation created four tiers of insurance - bronze, silver, gold and platinum. The different levels represent the amount of medical costs a patient could expect their insurance to contribute: 60, 70, 80 or 90 percent. But within each tier there are dozens of plan designs that give buyers the choice of different premiums, deductibles and networks of doctors, among other things. And the options are different in each state. The A.C.A.'s target audience included both low-earning Americans - those too wealthy to qualify for Medicaid but too poor to afford commercial insurance - and those who could not buy insurance through an employer, either because they were self-employed or because their jobs for small companies didn't offer coverage.
The research thus far suggests that the differences between plans offered through the A.C.A. and those offered by employers may be quite significant. A study in the policy journal Health Affairs found that out-of-pocket prescription costs were twice as high in a typical silver plan - the most popular choice - as they were in the average employer offering. In research conducted with the Robert Wood Johnson Foundation, Dr. Polsky found that 41 percent of silver plans offered a "narrow or very narrow" selection of doctors, meaning at best 25 percent of physicians in an area were included. The consulting firm Avalere Health found that exchange plans had 42 percent fewer cancer and cardiac specialists, compared with employer-provided coverage.
Some of the problems may have been predictable. When designing the new plans, for-profit insurers naturally tended to exclude high-cost, high-end hospitals with whom they had little clout to negotiate discounts. That means, for example, that as of late last year none of the plans available in New York had Memorial Sloan Kettering Cancer Center in their network - an absence that would be unacceptable to many New York-based employers buying policies for their employees. Another issue is out-of-state coverage, which many A.C.A. plans don't offer aside from emergencies, and which is routinely offered in policies from companies - especially large ones - with workers in more than one state.
As a result, many parents who were excited that they would be able to keep their children on their policies until age 26 have discovered that this promise has gone unfulfilled. When Sara Hamilton of New York was shopping on the exchange for a plan to cover her and her two young-adult children - who live in distant states - she discovered that none of the plans covered doctor visits in those places.
And when Simon F. Haeder of the University of Wisconsin and his colleagues studied the plans sold on the California exchange, they found that they included 34 percent fewer hospitals than those sold on the open market and tended to exclude the priciest medical centers, like Cedars Sinai, a highly regarded hospital that runs the largest heart-transplant program in the country.
Plan size, of course, is not the only consideration. The research also showed that those limitations might not matter so much for patients' health: The distance traveled and the quality of the providers was similar under both types of policies. He acknowledged, however, that California's exchange, called Covered California, has higher standards for plans than others do, and those results may not be typical.
For certain patients, narrower networks can be attractive because they tend to have lower premiums. A recent analysis by the management consulting firm McKinsey & Company found that premiums were 22 percent higher for plans with broad, as opposed to narrow, networks.
Meanwhile, as researchers continue to evaluate the pros and cons of new exchange plans, patients are discovering the pitfalls.
In 2013, Angie Purtell of Tega Cay, S.C., bought a gold plan offered by Coventry Health Care. When notified that the plan would double its monthly premium the following year, to nearly $1,000, she went shopping again on the state exchange and chose a Blue Cross silver plan for $500. It was branded "Choice."
But when she tried to visit her longtime doctor using the new plan, she found she could not. The doctor's practice, while in South Carolina, was not covered because it is affiliated with the Carolina Medical Center, a few miles over the border in Charlotte, N.C.
In order to make smart choices, patients need far clearer and more accurate information about the plans' restrictions as well as which doctors and hospitals are in the network. Yet such information is rarely available, and early research suggests that only a fraction of the doctors listed in some directories are available to see new patients.
"Now that you have the A.C.A., we really need to talk about what is an adequate network," Mr. Haeder said. "But we can't really talk about that until we know that the listings are accurate, and they're not."
ACROSS the country, lawmakers and regulators are refining the plans' requirements to make sure they work better. And regulators are trying to mandate better information, provided in a more consumer-friendly format.
As of this year, the government requires all the plans listed on the national online exchange - used by 38 states - to provide accurate, up-to-date directories. But such directories are often hundreds of pages long, and there is little enforcement. Even the government advises consumers to double-check with their insurers.
The Centers for Medicare and Medicaid Services recently proposed that states develop quantitative requirements for adequate networks - how many specialists of a certain type, for example, are necessary in a specific geographic area. But after protests from insurers and some states, the agency settled - for now - on a more limited fix that allows states and insurers more time to address the problem.
Next year, the government will begin requiring insurers to label plans "standard" (an average number of doctors for an exchange plan) versus "broad" or "basic" for those offering more or less choice. A few states are enacting their own laws.
But health and consumer advocates say progress is too slow, often leaving patients in the dark as they struggle to buy and use the new plans. Even as conservatives in Congress and the presumptive Republican presidential nominee, Donald J. Trump, have vowed to repeal the A.C.A., many consumers just want the system to work better.
"I'm putting my energy into improving transparency and information," Dr. Polsky said. "Otherwise, we're headed to a poorly implemented strategy that just ticks people off."
Elisabeth Rosenthal (@nytrosenthal) is a New York Times correspondent who is writing a book about the health care system. A continuing conversation about health care costs and pricing in the United States is on the Facebook group page Paying Till It Hurts.
DRAWINGS: DRAWING (DRAWING BY SELMAN DESIGN) (SR1); DRAWINGS (SR6)
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January 7, 2016 Thursday
Late Edition - Final
House Bill Undoing Health Law Makes It to Obama
BYLINE: By JENNIFER STEINHAUER
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1126 words
WASHINGTON -- As its opening move in the newly convened Congress, the House voted Wednesday to repeal the Affordable Care Act, the 62nd such vote but the first time that a bill will make it to President Obama's desk, forcing a rare veto to protect his signature domestic achievement.
The measure passed easily, 240 to 181.
While Democrats dismissed the bill -- which would also remove funding for Planned Parenthood -- as another ploy in the partisan drama that has played out in the Capitol since the law was enacted in 2010, the vote proved that a Republican congressional majority could deliver a measure that repeals the health law to a Republican president, even in the face of united opposition from Democrats.
It also shows that nearly six years after its enactment, the law remains a divisive political issue not only because it is associated with Mr. Obama, but also because for much of the middle class, it is at least perceived as costly and lessening consumer choice, polls show.
''This is a big deal,'' said Bill Hoagland, senior vice president of the Bipartisan Policy Center in Washington and a former longtime Republican staff member on the Senate Budget Committee. ''This vote sends the signal to the president and the American people there are changes that need to be made in this law.''
Even among Republicans, Mr. Hoagland said, ''there is a recognition that you may not do away with a number of the provisions that are popular.'' But, he added, ''if you can push away the politics of it, you will find there are a number of provisions that Democrats would agree could be changed,'' no matter who is president.
Mr. Obama's promised veto, only the eighth of his presidency, will be the most consequential so far. Republicans do not have sufficient votes to override the president. The White House and its allies had long expected that the antipathy for the health care law would wane as coverage increased and other policy fights arose.
Indeed, government surveys suggest that more than 17 million uninsured people have gained coverage since Congress adopted the health care law in 2010. And many of its components, such as mandatory coverage for pre-existing conditions and the ability for insured to cover young adult children, are very popular.
''We are in the final weeks of Open Enrollment for 2016 under the Affordable Care Act and saw unprecedented demand for January 2016 coverage,'' Sylvia Mathews Burwell, the secretary of health and human services, said in a statement. ''Yet at the same time, we continue to see efforts to repeal the A.C.A. and turn back the clock.''
Democrats in Congress were quick to criticize the vote.
''This is a sad and shameful way to begin the new year,'' Representative Chris Van Hollen, Democrat of Maryland, said on the House floor Wednesday. ''With all the pressing issues we face at home and abroad,'' he said, Republicans chose ''to take away access to affordable care to 22 million Americans.''
Yet public opposition to the law has ticked up again in recent months, in part because the cost of coverage from the law's insurance exchanges is rising in many states for 2016. The most recent Kaiser Family Foundation tracking poll found 46 percent of Americans had an unfavorable opinion of the law, compared with 40 percent who viewed it favorably. This has left the law a weapon of choice for Republicans in Congress, particularly in an election year in which Speaker Paul A. Ryan is seeking to set the policy agenda.
''A lot of what members on my side of the aisle predicted has come to pass,'' said Senator Susan Collins, Republican of Maine, citing increased premiums, higher deductibles and confusion among employers as to what constitutes full-time work. ''A lot of the issues that directly affect people's pocket books have turned out to be negative. I continue to believe, however, that our party must have a plan for replacing and fixing Obamacare and not just repealing it.''
Republicans concede that if they win the White House, simply repealing the law will no longer be sufficient. Republicans in Congress have yet to offer a comprehensive replacement for the law. Instead, much of their focus, beyond the health care law, has been on attacking Planned Parenthood.
''We were elected on a pledge to try and repeal Obamacare,'' said Representative David Jolly, Republican of Florida. ''If we are unsuccessful in a veto override, I think we should turn our attention to other matters like national security. But if we get a Republican in the White House, then we need to turn to solutions. The focus can't be just on repealing Obamacare. It has to be, 'What is our health care plan?'''
Republicans say that the health law remains potent for them in part because some of its flaws, like rising premium costs, have only begun to be revealed, even as many of its more popular provisions were quickly clear.
''Even though the law was passed many years ago, the rollout is much more recent, and some components haven't even been implemented,'' said Representative Lee Zeldin, Republican of New York. ''For a few years the debate over Obamacare was one about how it was going to impact individuals, families and businesses in the future. And when it actually started, the debate shifted and people had their own personal stories to tell.''
''I would say constituents have been very upset with the failure of the New York co-op,'' he said, referring to the Health Republic Insurance of New York.
But for Republicans to succeed in dismantling the law, they need to maintain control of the Senate, as well as win the White House. Their majority in the Senate enabled them to pass the repeal measure through a budget procedure called reconciliation, which requires only a simple majority vote and avoids a filibuster, which would require 60 votes.
While the House at first struggled to make that process work, Senator Mitch McConnell, Republican of Kentucky and the majority leader, used his parliamentary skills to make it work and also attack Planned Parenthood.
''The Senate was never able to muster the votes required to send the legislation to the president's desk,'' Mr. Zeldin said. ''So this moment in time is unique compared to the past history.''
Although Republicans will almost certainly fail in this latest bid, the issue is all but certain to animate the race for the White House and in Senate and House contests.
''I can assure you this is not the end,'' Mr. Hoagland said. ''We will continue to have the discussion about health care, its costs and how to it to the American public at the least cost with the best care.''
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URL: http://www.nytimes.com/2016/01/07/us/politics/house-votes-to-send-bill-to-repeal-health-law-to-obamas-desk.html
LOAD-DATE: January 7, 2016
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The New York Times
June 22, 2012 Friday
Late Edition - Final
Billions of Dollars in Play Over Health Care Law
BYLINE: By REED ABELSON
SECTION: Section A; Column 0; Business/Financial Desk; Pg. 1
LENGTH: 1245 words
PEEKSKILL, N.Y. -- In this small city about an hour from Manhattan, pregnant teenagers, laid-off professionals and day laborers without insurance receive care at a community health center that has been part of the social fabric here for nearly four decades.
Because of the sweeping federal health care law passed two years ago, the center, part of the Hudson River HealthCare network, received a $4.5 million grant last month to expand. It plans to add six more medical and seven more dental exam rooms, allowing it to see as many as 5,000 additional patients, many of whom are without insurance, on Medicaid or have limited coverage. An additional 730 community centers or so like it are to be renovated or built across the country in the next two years for patients like that.
Unless the Supreme Court says otherwise.
By the end of June, the court is expected to decide whether some or all of the Obama administration's health care law is constitutional. While speculation has focused on how the decision would affect the future of the nation's health insurance market, little attention has been paid to the tens of billions of dollars in federal money appropriated for a host of other provisions in the law.
Exactly what happens to the money for those programs if the Supreme Court decides to overturn the entire law is unclear. Tens of billions of dollars could easily vanish, especially depending on the outcome of the November elections. Congress and the president could always decide to cut the funds for any of these initiatives, especially given pressing political and budgetary realities.
Critics of the law, particularly Congressional Republicans, argue that much of the spending already allocated and authorized is wasteful. They have been particularly concerned over the Prevention and Public Health Fund, whose funds have already been cut by a third as lawmakers sought to find money for other programs.
''Instead of helping Americans prevent health problems, the president's new law actually uses this so-called prevention fund as a Washington slush fund,'' Senator John Barrasso, a Republican from Wyoming, said last month.
He was one of a group of senators calling for the elimination of the fund. Critics cite programs like those improving sidewalks or creating community gardens as frivolous, and Republicans have argued for more accountability over how the money is being spent.
The Affordable Care Act allocates money for such diverse efforts as creating insurance programs for people who have pre-existing medical conditions and cannot find private coverage, offsetting employers' costs for early-retiree health plans, bumping up the pay for some primary care doctors and a broad array of public health initiatives, like funds for state vaccination programs.
All told, at least $13.7 billion in federal money has already been spent, according to estimates from the Kaiser Family Foundation, a nonpartisan research group that is closely tracking the federal funds. The largest share of future spending, some $1 trillion, is expected to pay for expanding coverage. But the law also calls for significant sums -- $100 billion has already been appropriated -- to be spent over the next decade on other initiatives aimed at improving the nation's health care system.
Community health centers, for example, are to receive $11 billion under the law with about $10 billion more designated for a new effort to improve public health. An additional $2 billion has been appropriated to states for care for the aged outside of nursing homes, and there is also $350 million to combat fraud and waste in Medicare. About $200 million is to go to school-based health centers.
If the court strikes down the entire law, many experts are skeptical that lawmakers will go ahead with funds for programs like the new Prevention and Public Health Fund, even if they are completely distinct from the controversial aspects of the law seeking to overhaul the insurance markets.
''I have no confidence that Congress will turn around and adequately fund the public health system,'' said Dr. Georges C. Benjamin, the executive director of the American Public Health Association, which represents people working in public health. The federal law sought to remedy years of underinvestment, he said.
The fate of programs like the federally financed state pools for people who cannot get private insurance that were expected to end as soon as the full law went into effect in 2014, when insurers would be required to cover everyone, is also unclear.
About 70,000 people have enrolled in these programs. About $1 billion has been spent so far to help subsidize their coverage and an additional $4 billion has been authorized under the law to keep the programs until 2014.
As a result, people like Linda Ellis, 64, are now insured. Ms. Ellis could not find a private insurance company to cover her when she lost her employer-sponsored plan after being laid off. Her husband is already enrolled in the federal Medicare program, so she had to try to find coverage on her own. She was not eligible for the state Medicaid program. Because of a shoulder condition and minor ailments like sinusitis, no one would offer her a policy when she scrambled to find coverage.
''People don't realize you can get rejected in the private market even if it's not life-threatening,'' said Ms. Ellis, who now pays $428 a month for insurance from a federally financed state program in Ohio. Ms. Ellis had contacted Families USA, a consumer advocacy group that provided her contact information to The New York Times.
But Ms. Ellis said she had no idea whether she would continue to be covered if the Supreme Court declared the entire law unconstitutional. When she asked the office of her United States senator, she was told no one could say, and federal officials declined to comment on what might happen to any program now financed under the law. ''Obviously I'm concerned,'' she said.
The largest share of the money to date, about $5 billion, has gone to employers, public retirement plans, unions and others that provide insurance coverage for workers who retire before they are eligible for Medicare. Under this early-retiree program, General Electric and the United Automobile Workers were among those entities receiving money.
G.E., for one, said it had used the $39 million it received under the program to reduce its costs and the costs of both active and retired employees. Republicans like Senator Mike Enzi from Wyoming have argued that much of the money went to unions and state retirement plans as a way of rewarding ''politically connected constituencies.''
But Larry Levitt, a senior executive at the Kaiser Family Foundation, said, ''Retiree coverage has been under threat for quite a while now.'' One of the law's aims, he said, is to create programs to help companies and workers make it to 2014, when all the insurance regulations was expected to go into effect.
This article has been revised to reflect the following correction:
URL: http://www.nytimes.com
LOAD-DATE: June 25, 2012
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GRAPHIC: PHOTOS: Alda Vintimilla and her daughter receiving care at the Hudson River Community Health Care Center in Peekskill, N.Y.
Patients at the Peekskill center, which may or may not get to keep a $4.5 million federal grant.
The Peekskill center, which plans to use the $4.5 million from the Affordable Care Act to expand and serve more patients. (PHOTOGRAPHS BY BENJAMIN NORMAN FOR THE NEW YORK TIMES) (A3) CHARTS: Where the Money Has Gone: The federal government has distributed at least $13.7 billion to date to various government and private groups as part of the Patient Protection and Affordable Care Act, the federal health care law passed in 2010. (Source: The Henry J. Kaiser Family Foundation) (A3)
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The New York Times
October 21, 2014 Tuesday
Late Edition - Final
Uninsured and Unaware of Next Open Enrollment
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; A SURVEY SAYS; Pg. 3
LENGTH: 678 words
This year, the big challenge for officials behind the Affordable Care Act may not be making the website work but getting customers to come shop in the first place.
A new survey of people without health insurance highlights the challenge: It found that 89 percent of the people surveyed were unaware that open enrollment begins in November, or any time soon.
That's a big deal because, unlike last year, the enrollment period for marketplace plans is only three months long. Most people who want to buy policies on new state marketplaces need to pick their plan between Nov. 15 and Feb. 15, or they'll have to wait another year.
Under the Affordable Care Act, most Americans are required to obtain health insurance or pay a fine, and projections from the Congressional Budget Office estimate that millions more will enroll this year. People with incomes low enough to qualify for Medicaid -- about $27,000 for a family of three -- can sign up for insurance at any time. But the open enrollment period applies to everyone else who doesn't experience a major life change during the year, such as losing a job or getting divorced. Of course, in order to sign up for coverage, eligible people need to know it's available.
According to Mollyann Brodie, who conducted the survey for the Kaiser Family Foundation, a health care research group, the results mirror what surveys showed last fall, before the first open enrollment period. But given all the news coverage of the Affordable Care Act since then, and the experiences of the millions who gained coverage, she was not expecting awareness among those without insurance to stay so low.
''Having just no idea it's coming -- that's pretty surprising at this point,'' she said. ''You'd think there's just been so much attention and effort put out there.''
The start date wasn't the only thing that the uninsured didn't know. According to the survey, two-thirds of the uninsured said they know ''only a little'' or ''nothing at all'' about the health insurance marketplaces. More than half said they were not aware that they might qualify for financial assistance to help them afford their premiums -- a key motivator to sign up, since several surveys have shown that many uninsured people are worried about the cost of coverage.
Last year, despite myriad technical problems, more than 8 million Americans succeeded in selecting health plans on the new website. About 7.3 million people are currently enrolled in marketplace plans, according to the latest count from the Department of Health and Human Services. It's unclear how well the site will work this time around, but H.H.S. officials have been promising a smoother consumer experience.
Experts who study the uninsured say that the first wave of enrollees was probably the most aware and motivated group of uninsured people in the country. Spreading awareness among the remaining uninsured will be a bigger challenge. Many have been without health insurance for years and have little contact with the health care system. Ms. Brodie said that many people in her survey did not speak English as a first language.
''Those who remain uninsured are likely fundamentally harder to reach than those who enrolled in the first enrollment period,'' said Anne Filipic, the president of Enroll America, a group funded by foundations and the health care industry and devoted to spreading the word about the new health insurance options.
Still, Ms. Filipic said she was optimistic that her organization would be able to reach this population in time. It has spent the last year collecting lists of people who will be eligible for coverage options. Enroll America's research suggests that many people who are uninsured will want coverage once they understand how the law works, she said.
''Though they may be harder to reach, they are not necessarily harder to convince,'' she said.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter.
The Upshot provides news, analysis and graphics about politics, policy and everyday life.
URL: http://www.nytimes.com/2014/10/21/upshot/next-open-enrollment-for-aca-approaches-but-few-notice.html
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GRAPHIC: PHOTO: People in New Britain, Conn., signing up for health coverage before the March deadline this year. Another enrollment period starts Nov. 15. (PHOTOGRAPH BY JESSICA HILL/ASSOCIATED PRESS)
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The New York Times Blogs
(Taking Note)
October 6, 2015 Tuesday
'If She's a Feminist Then I'm a T. Rex': Readers on Carly Fiorina
BYLINE: MARIE TESSIER
SECTION: OPINION
LENGTH: 467 words
HIGHLIGHT: While Mrs. Fiorina’s positions disturb some readers, others say she deserves credit for succeeding as a woman in the corporate world.
While Carly Fiorina's positions on abortion rights and the future of Planned Parenthood are anathema to some readers concerned about women's rights, others say she deserves credit for succeeding as a woman in the corporate world.
"She deserves our support for trailblazing a path which has helped every female executive, no matter her politics, who has successfully worked her way up the corporate ladder," Feminist in Tampa wrote in response to a recent Room for Debate forum. "I may not vote for her, but she is a role model for every girl in this country who wants to succeed in the technology sector still mostly controlled by men."
As C.E.O. of Hewlett-Packard, Mrs. Fiorina was the first woman to lead a Fortune 20 company. Hewlett-Packard's poor performance during her tenure has been a point of criticism of her candidacy.
Some readers said a feminist is a woman who makes independent choices, regardless of her position on specific issues.
"I abhor Fiorina's politics, but she's correct that feminism is a woman leading the life she chooses, in spite of what men want on both the individual and social levels," Jenifer Wolf in New York City wrote.
But just being a successful woman doesn't make Mrs. Fiorina a feminist, some readers argued.
"Carly is not promoting policies that would help women in this country such as health care, child care, and equal pay," Abelle in Portland, Ore., wrote of the candidate, who has promoted the repeal of the Affordable Care Act. "Just because she is a strong woman doesn't mean she promotes women's equality in public life."
Others said it's problematic for Mrs. Fiorina to trumpet her status as a leader.
"Her record at Hewlett-Packard - firing skilled Americans by the thousands and outsourcing their jobs to China and India, while almost running her company into the ground with an ill-advised merger - is hardly a sterling record for any sort of candidate, assuming we actually want a president of all the people rather than a modern Ebenezer Scrooge," Grossness54 wrote from West Palm Beach, Fla. "This is a woman who would deny other women control over their own bodies, as well. If she's a feminist then I'm a T. rex."
In a recent column, David Brooks described Mrs. Fiorina as "stylistically indomitable" and called her a "marketing genius." However, he wrote "for all her feisty outsider bravado, if you actually look at her views on substance and her behavior in the past, she is a completely conventional Republican." And at Hewlett-Packard, he said, "she made the classic marketer's error, letting her promises get far out in front of reality."
Like Mr. Brooks, many readers expressed skepticism about Mrs. Fiorina's leadership abilities.
"If she is such a marketing genius," John W. Lusk wrote from Danbury, Conn., "why hasn't another company hired her?"
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The New York Times Blogs
(Economix)
October 7, 2013 Monday
The Color of Affordable Care
BYLINE: NANCY FOLBRE
SECTION: BUSINESS; economy
LENGTH: 1142 words
HIGHLIGHT: Patterns of political opposition to the Affordable Care Act reflect a lightly camouflaged legacy of racial inequality, an economist writes.
Nancy Folbre is professor emerita of economics at the University of Massachusetts, Amherst.
Shortly after House Republicans shut down the federal government in an effort to halt implementation of the Affordable Care Act, Sabrina Tavernise and Robert Gebeloff of The New York Times reported that many Republican-controlled states have already strangled an important feature of the legislation by denying extension of Medicaid eligibility to the working poor.
Since the federal government committed to shouldering most of the cost of such extensions, the officials running these states seem to be cutting off their own noses to spite their faces. Then again, perhaps the noses they are cutting off are not their own.
Neither Republican officials nor their most valuable constituencies need help paying for health insurance. When they say they oppose government spending what they really mean is that they oppose spending on programs like Medicaid that - unlike universal programs such as Social Security - target low-income families.
The disparate racial impact is striking: 68 percent of poor and uninsured blacks live in states that are not extending eligibility, compared with 58 percent of poor and uninsured persons in other racial categories.
The concentration of negative effects in Southern states that also represent the stronghold of Congressional opposition to the law itself is not surprising. This episode of political history fits neatly into an established line of research that shows how federal efforts to extend protections to the disadvantaged have repeatedly fallen prey to a toxic blend of racial and regional politics. From civil rights to health insurance, white political leaders from states with large numbers of African-Americans - especially but not exclusively in the South - have cast new federal protections in apocalyptic terms and mounted a powerful opposition.
In her pioneering book "The Color of Welfare," published in 1994, the sociologist Jill Quadagno persuasively documented the race-based politics that sent the United States down a policy path very different from that of other affluent countries, blocking the federal extension of most universal social programs other than Social Security and Medicare and giving states significant control over means-tested programs targeted at the poor. This control allowed politicians in Southern states to restrict benefits for low-income families, whatever their color.
A host of academic studies have explored the impact of intersections between race and class, noting, for instance, that in states with larger black populations race becomes more salient to the politics of social provision, altering the dynamics of social and political trust. Poor whites are promised protection against labor market competition or higher taxes in return for acquiescence with policies that restrict the social safety net.
As the Stanford economist Gavin Wright shows in his new history of the Civil Rights Movement, "Sharing the Prize," Southern whites often overestimated the costs - and underestimated the benefits - that integration would bring them.
In "Disciplining the Poor," an analysis of welfare reforms introduced in the mid-1990s, Joe Soss, Richard C. Fording and Sanford F. Schram demonstrate that states with a large number of African-Americans (especially but not exclusively in the South) imposed particularly stringent rules on access to public cash assistance, as well as keeping benefit levels extremely low.
In "Taxing the Poor," Katherine Newman and Rourke O'Brien show that state income and sales taxes in the South are far more regressive than those in other regions of the country, penalizing all low-income families.
Overt racism and outright discrimination now elicit strong social disapproval, but racial bias takes a more subtle, coded form. In "Why Americans Hate Welfare," Martin Gilens documents a tendency for Americans to systematically overestimate the percentage of public welfare spending going to blacks. His content analysis of pictures accompanying stories about poverty in three major newsmagazines between 1967 and 1992 showed that the frequency with which African-Americans were depicted far exceeded their actual representation in the population.
An Associated Press survey of racial attitudes conducted immediately before the presidential election last year clearly suggests that most Americans try not to discriminate, but that racial loyalties shape their perceptions of economic benefits.
When asked if President Obama's race affected the likelihood they would vote for him, 80 percent of respondents said no. Yet 28 percent of respondents believed that his policies had made black Americans better off, compared with only 15 percent who believed they had made white Americans better off.
I don't know of any analysis of the president's economic stimulus program - or any other policy - purporting to show that blacks benefited more than whites. Indeed, the comparison itself is oddly optimistic, because neither black nor white Americans outside the top 1 percent of the population have enjoyed significant increases in family income since 2009.
Respondents predisposed to believe that a black president will try to benefit blacks more than whites are likely to view the Affordable Care Act through a racial lens, which helps explain the results of a recent Pew survey showing that almost 91 percent of blacks currently approve of the law, compared with 29 percent of whites.
This approval gap overshadows the effect of factors directly relevant to eligibility for assistance. Among those with annual family incomes of less than $50,000, 50 percent currently approve of the law, compared with 38 percent of those with higher incomes (who are less likely to benefit from it).
It's important to note that many people who don't approve (about 17 percent, according to a recent Kaiser Foundation poll) feel the Affordable Care Act doesn't go far enough in reforming the way we pay for health care. Further, the complexity of the legislation makes it difficult for individuals to predict its economic consequences (the Pew survey reported that only 25 percent of poll respondents said they had a very good understanding of how the law would affect them).
Controversy and confusion make it easier for politicians to prey on pre-existing prejudices that serve their own interests better than those of their least influential constituents, as became apparent in the first stage of the civil rights movement.
This movement has yet to reach its final stage. Access to affordable health insurance should be considered a civil right for everyone.
Dealing With Drafting Errors in the Health Care Law
Shutdown Savings and the Debt Ceiling
Remember Sequestration?
How a Debt-Ceiling Crisis Could Become a Financial Crisis
More on Dysfunctionology: Minority Rules
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The New York Times
October 25, 2016 Tuesday
Late Edition - Final
Choices Fall in Health Law as Costs Rise
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1019 words
WASHINGTON -- Premiums for midlevel health plans under the Affordable Care Act will increase by an average of 25 percent next year, while consumers in some states will find significantly fewer insurance companies offering coverage, the federal government said Monday.
But the Obama administration said three-fourths of consumers would still be able to find plans for less than $100 a month with the help of federal subsidies.
The open enrollment period under President Obama's signature health law begins on Nov. 1, but consumers got their first look at their options on Monday. Consumers who go without insurance next year could face possible tax penalties of $700 a person or more.
In many parts of the country, the available options are sure to become part of the political conversation in the election season's closing days. And the rising costs and shrinking options all but ensure that the next president will need to make significant adjustments to the health law, something both Hillary Clinton and Donald J. Trump have promised.
The average increase of 25 percent in benchmark premiums on the federal exchange compares with increases of 2 percent in 2015 and 7 percent this year. Major insurers have pulled out of the public marketplace in many states, citing multimillion-dollar losses, and state officials have approved rate increases of 25 to 50 percent or more for some insurers that remain.
One in five consumers on the federal health insurance website HealthCare.gov will find only one insurer with offerings next year, the administration said.
For a 27-year-old consumer, in the prime age group sought by insurers, the average monthly premium for a benchmark plan would be $302 next year, up from $242 this year, according to a report from the Department of Health and Human Services.
''While the president's allies in Washington will try to spin the numbers, families across the country will be forced to figure out how to pay for such unaffordable insurance,'' said Senator Orrin G. Hatch, Republican of Utah, who is an opponent of the Affordable Care Act and the chairman of the Senate Finance Committee, which has jurisdiction over much of the law.
The administration minimized the marketplace's troubles. Officials said people could lower their costs by seeking income-based subsidies in the form of tax credits and by switching to less expensive plans. While some markets will have few choices, consumers nationwide will see an average of 10 plans per insurer. Plans vary in cost and cover different doctors, hospitals and drugs.
The Obama administration said last week that it expected monthly enrollment in the Affordable Care Act marketplace to average 11.4 million next year, up from a monthly average of 10.5 million this year. But five million to seven million people who buy insurance on their own do not receive federal subsidies.
''The number of people eligible for tax credits will increase'' as premiums rise next year, and the amount of assistance will also increase, Kevin Griffis, a spokesman for the Department of Health and Human Services, said.
Under the federal health law, insurance plans are classified in four levels: bronze, silver, gold and platinum, depending on the amount of coverage.
''If every returning consumer nationwide selected the lowest-cost plan within the same metal level they picked last year, average premiums -- taking into account financial assistance -- would fall by $28 per month, or 20 percent, compared with 2016,'' Kathryn E. Martin, an acting assistant secretary of health and human services, said.
But in many places, the options have shrunk.
Laura M. Schlett, 44, of Brandon, Miss., a suburb of Jackson, said she was losing coverage because her insurer, UnitedHealth, was pulling out of the public marketplace there, as in many other states.
Ms. Schlett said that she received a subsidy of $110 a month and spent $240 a month for health insurance with a $3,000 deductible this year.
''I can't afford to get sick after paying for the health insurance,'' Ms. Schlett said.
In Phoenix, only one insurer, Health Net, a subsidiary of Centene, is listed on HealthCare.gov, and it is offering only four plans for 2017. A Phoenix family of four with income of $62,000 a year could obtain a premium tax credit of $1,079 a month next year, but would still owe $342 a month, or roughly $4,100 a year, and the policy has an annual deductible of $14,100 for the family, according to HealthCare.gov.
In Raleigh, N.C., 18 plans are available for 2017 from two insurers, but the premiums could be a substantial expense for some consumers. For a 53-year-old man with income of $53,000 a year, the cheapest midlevel silver plan will cost $714 a month, or $8,568 a year, according to the federal website, and no subsidy would be available.
But a man of the same age with income of $25,000 a year could get a subsidy of $639 a month, reducing his premium to $75 a month, or $900 a year.
In Eugene, Ore., the cheapest silver plan available to a 35-year-old man has a full, unsubsidized premium of $348 a month, or $4,176 a year, and an annual deductible of $3,000. A total of 14 plans are available from two insurers.
In Charleston, W.Va., consumers have a choice of 16 plans offered by two insurers. For a 40-year-old woman, the cheapest silver plan has a full, unsubsidized premium of $505 a month, or $6,060 a year, and an annual deductible of $6,150. If the woman has annual income of $30,000, she could get a subsidy of $326 a month, but would still owe premiums of $179 a month, or about $2,150 a year.
Stabilizing the insurance marketplace could be a major challenge for Mrs. Clinton, the Democratic candidate for president, if she wins, as opinion polls suggest she will.
The assurances by the Obama administration on Monday differed in tone from Mrs. Clinton's remarks on the campaign trail. She has supported the Affordable Care Act, but denounced ''skyrocketing out-of-pocket health costs'' and said the federal government should have the power to block or modify unreasonable rate increases so coverage would be more affordable.
URL: http://www.nytimes.com/2016/10/25/us/some-health-plan-costs-to-increase-by-an-average-of-25-percent-us-says.html
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The New York Times Blogs
(The Caucus)
March 23, 2012 Friday
A Democratic Embrace for 'ObamaCare'
BYLINE: JACKIE CALMES
SECTION: US; politics
LENGTH: 321 words
HIGHLIGHT: The Obama campaign says it's time to give the term Obamacare "the love it deserves."
After two years, "ObamaCare" is an epithet no more. The Obama campaign says so.
On Friday, the second anniversary of the day President Obama signed the law expanding health insurance -- and two days before the Supreme Court opens arguments on its constitutionality -- his re-election campaign has embraced the term that Republicans have long used to deride the measure.
The law is the president's signature domestic achievement, but still a widely unpopular one -- thanks in part to the sustained Republican assault that Democrats never countered in kind -- at least until now.
Jim Messina, the Obama campaign manager, wrote in a fundraising e-mail: "It's about time we give it the love it deserves. Let everyone know: 'I like ObamaCare'."
With such prodding, supporters wrote endorsements on Facebook and on their Twitter accounts, making "#ILikeObamaCare" a trending topic on Twitter.
Jennifer O'Malley Dillon, the deputy campaign manager, sent out her own tweets and re-tweeted others, including this one: "Happy birthday to ObamaCare: two years in, the Affordable Care Act is making millions of Americans' lives better every day."
In the past, Mr. Obama, at occasional party fund-raisers, has said he does not mind that Republicans have called the law "ObamaCare," saying they are right: "Obama cares." But while the White House and his campaign had never done much to push back against use of the word -- perhaps hoping for the day that they would want to own it -- they had not until now taken ownership.
The move to do so on Friday countered Republicans' own campaign on the law's second anniversary, taunting the White House for not doing anything special to observe the day.
"Today is the 2nd anniversary of ObamaCare, a milestone the president is not celebrating. Why? He doesn't want to defend it," Sean Spicer, the communications director of the Republican National Committee, wrote in an e-mail he circulated widely.
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The New York Times
November 9, 2014 Sunday
Late Edition - Final
Before Battling Democrats, G.O.P. Is Fighting Itself
BYLINE: By JEREMY W. PETERS; Jonathan Martin contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1269 words
WASHINGTON -- As most Republicans were taking a victory lap the morning after the elections, a group of conservatives huddled anxiously in a conference room not far from Capitol Hill and agreed that now is the time for confrontation, not compromise and conciliation.
Despite Republicans' ascension to Senate control and an expanded House majority, many conservatives from the party's activist wing fear that congressional leaders are already being too timid with President Obama.
They do not want to hear that government shutdowns are off the table or that repealing the Affordable Care Act is impossible -- two things Republican leaders have said in recent days.
''If the new Republican leadership in the Senate is only talking about what they can't do, that's going to be very demoralizing,'' said Thomas J. Fitton, president of Judicial Watch, a conservative advocacy group that convenes a regular gathering called Groundswell. Any sense of triumph at its meeting last week was fleeting.
''I think the members of the leadership need to decide what they're willing to shut down the government over,'' Mr. Fitton said.
Establishment Republicans, who had vowed to thwart the Tea Party, succeeded in electing new lawmakers who are, for the most part, less rebellious. And when the new Congress convenes in January, the Republican leaders who will take the reins will be mainly in the mold of conservatives who have tried to keep the Tea Party in check.
But they have not crushed the movement's spirit.
As Republicans on Capitol Hill transition from being the opposition party to being one that has to show it can govern, a powerful tension is emerging: how to move forward with an agenda that challenges the president without self-destructing.
Some conservatives believe that the threat of another shutdown is their strongest leverage to demand concessions on the health care law and to stop the president from carrying out immigration reform through executive order. Yet their leadership has dismissed the idea as a suicide mission that could squander the recent gains.
One thing that will prove popular among the base is a commitment by Senator Mitch McConnell, the presumptive new majority leader, to bring up a bill that would ban abortions after 20 weeks of pregnancy, which he is expected to do next year.
Whether the party can reconcile more demands of its base with the will of its leadership could determine how enduring the Republican Senate majority will be. The crop of senators up for re-election in 2016 includes those elected in the first Tea Party wave of 2010. And in a sign of what is at stake, even some of them are sounding notes of compromise and caution that would have been unthinkable at the height of the right's resurgence.
''I understand the frustrations of the conservative base; I am one of them,'' said Senator Ron Johnson of Wisconsin, one of the original class of Tea Party-inspired senators. ''I also recognize reality.''
''We're not going to pass the entire conservative agenda tomorrow. We can certainly lay it out,'' Mr. Johnson added. ''Let's start with the things we can pass. Doesn't that make more sense?''
But in a stark reminder of the difficulties Republican leaders will face from within their own ranks, other lawmakers popular with the Tea Party base are saying the fight is on.
As votes were still being counted on election night Tuesday, Senator Ted Cruz of Texas said Republicans could still work through Congress to dismantle the Affordable Care Act -- even though the president is guaranteed to veto anything Congress passes that undermines it. ''After winning a historic majority, it is incumbent on us to honor promises and do everything humanly possible to stop Obamacare,'' Mr. Cruz said in an interview.
Some Republican senators rejected that outright. ''There are intelligent things to do, and there are some not-so-intelligent things to do,'' said Senator Orrin G. Hatch of Utah. ''And one of the first things we should do is find some areas of common ground with our Democrat friends.''
Tea Party conservatives, many of whom argue that the government shutdown last year was a sound strategy, said they were baffled by remarks after the election by Mr. McConnell that the Senate under his control would prioritize policies that Republicans knew Democrats would also support.
Many also fumed when Mr. McConnell stated the obvious: Republicans do not have the votes to repeal the Affordable Care Act because they cannot override a presidential veto on their own. (It takes 67 votes to do so; they have 52 seats now, with the possibility of picking up two more.) The next day, he and Speaker John A. Boehner of Ohio wrote an op-ed for The Wall Street Journal insisting that, indeed, repeal remained a goal.
Any perception that Mr. McConnell is not sufficiently committed to repealing the health care law, despite his running hard against it in his own re-election campaign, would renew the same fissures among Republicans that preceded the government shutdown.
''That would cause a civil war inside the Republican Party,'' said Richard Viguerie, a longtime conservative activist, referring to anything the party's base saw as a halfhearted attempt at repeal. ''There's almost zero trust between the base and the Republican leaders.''
No one did more to demoralize Tea Party candidates and conservative agitators than Mr. McConnell, who vowed to ''crush'' every Republican primary challenger. (He did; none defeated an incumbent senator.) He also blacklisted Republicans who worked with groups supporting insurgents.
Privately, McConnell aides say they are less concerned these days about the impact of senators like Mr. Cruz, whom they describe as an ''army of one.'' Mr. McConnell believes his standing with conservative voters is solid. And he has the votes to prove it. He won his own primary over a Tea Party conservative, 60 percent to 35 percent. An NBC News/Marist College poll showed him beating his main primary opponent 53 percent to 33 percent among Tea Party voters.
He and his allies dismiss their Tea Party opponents as ''for-profit conservatives'' because of the fund-raising they do in the name of purifying the Republican brand.
''The for-profit wing of the Republican Party will always have a voice, but after this last election, they don't have much credibility,'' said Scott Reed, the U.S. Chamber of Commerce's senior political strategist. ''I'm not sure many folks will listen to it much longer. Governing still matters, and the good news is, everybody who was elected is into governing.''
Most of the Republicans just elected to the Senate appear to be team players. Cory Gardner of Colorado, Shelley Moore Capito of West Virginia and Steve Daines of Montana are all low-key members of Congress. Thom Tillis of North Carolina is the speaker of the State House and a favorite of the party establishment.
Still, Tea Party conservatives are a formidable voting bloc. Mr. McConnell will have to negotiate an especially cautious balance between their demands and those of the senators in his conference who are contemplating running for president in 2016, and so need the support of the party's base. With no one is this more fraught than Mr. McConnell's fellow Kentuckian, Senator Rand Paul. Mr. Paul and his advisers say that they recognize Tea Party supporters helped deliver the Senate for the Republicans, and that the party ignores them at its peril.
''They showed up,'' said Doug Stafford, a senior adviser to Mr. Paul. ''You can't look at the turnout models, the polling pre-election and the results, and not think that conservatives showed up for this. They did.''
URL: http://www.nytimes.com/2014/11/09/us/politics/before-battling-democrats-gop-is-fighting-itself-.html
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GRAPHIC: PHOTO: Senators Mitch McConnell, left, and John Barrasso heading to a White House meeting Friday. (PHOTOGRAPH BY JABIN BOTSFORD/THE NEW YORK TIMES) (A27)
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The New York Times
January 19, 2017 Thursday
Late Edition - Final
A Presidency Ends: Farewells to Obama
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 26
LENGTH: 456 words
To the Editor:
Re ''The Optimism of Barack Obama'' (editorial, Jan. 15):
Millions of Americans will surely miss President Obama. We will miss the hope he inspires, and the model of a family that he and Michelle, Malia and Sasha provide.
I will miss his grace under pressure, his willingness to make decisions based on evidence, his compassion for all -- even those who disagree with him. I will miss his eloquence, his dedication and work ethic. No better example can be found than his herculean efforts to keep his successor from doing grave harm to the country Mr. Obama loves.
Most of all, though, I will miss his incredible ability to put aside personal emotions and focus on the goal and the best way to get there.
JOHN E. COLBERT
Arroyo Seco, N.M.
To the Editor:
The waning days of the Obama presidency have brought a raft of books, newspaper and magazine articles and television reviews on his legacy. They address among many possible subjects his foreign policy, his use of presidential authority and of course the Affordable Care Act. But perhaps the most significant element of his legacy is the election of Donald Trump.
What occurred during his presidency that led to the breakdown in the American political process? Of course a Republican Congress did not help. But in the end Mr. Obama failed to provide firm political leadership experienced and supported by the American electorate.
His leadership style can best be described as ''leading from behind.'' This is a style perhaps suited to a university president but not to the president of the United States. The victory of Donald Trump is its political renunciation.
SIDNEY WEISSMAN
Chicago
To the Editor:
Barack Obama, because of his superior character, in combination with a deep respect for the office, has chosen to refrain from fanning the widespread flames of fear, incredulity and anger framing a Donald Trump presidency.
President Obama's oratorical skills, paired with a keen intellect enabling him to digest complex issues, have served to establish his credibility as leader of the world's most visible country.
Economic indicators have risen dramatically during Mr. Obama's tenure. More Americans have health care coverage than ever before as a result of the Affordable Care Act. Mr. Obama has been at the forefront of a global initiative to address climate change.
Frustrated by the seemingly insurmountable mountain of resistance blocking gun control legislation, the president has nonetheless demonstrated an ability to empathetically connect emotionally with the victims of gun violence.
Though weathered by the storm, President Obama bequeaths a legacy of hope for the current and future generations.
ROBERT JUDKINS
Hendersonville, Tenn.
URL: http://www.nytimes.com/2017/01/18/opinion/a-presidency-ends-farewells-to-barack-obama.html
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The New York Times
January 18, 2017 Wednesday 00:00 EST
A Presidency Ends: Farewells to Barack Obama;
Letters
SECTION: OPINION
LENGTH: 449 words
HIGHLIGHT: Readers discuss the accomplishments and flaws of his administration.
To the Editor:
Re "The Optimism of Barack Obama" (editorial, Jan. 15):
Millions of Americans will surely miss President Obama. We will miss the hope he inspires, and the model of a family that he and Michelle, Malia and Sasha provide.
I will miss his grace under pressure, his willingness to make decisions based on evidence, his compassion for all - even those who disagree with him. I will miss his eloquence, his dedication and work ethic. No better example can be found than his herculean efforts to keep his successor from doing grave harm to the country Mr. Obama loves.
Most of all, though, I will miss his incredible ability to put aside personal emotions and focus on the goal and the best way to get there.
JOHN E. COLBERT
Arroyo Seco, N.M.
To the Editor:
The waning days of the Obama presidency have brought a raft of books, newspaper and magazine articles and television reviews on his legacy. They address among many possible subjects his foreign policy, his use of presidential authority and of course the Affordable Care Act. But perhaps the most significant element of his legacy is the election of Donald Trump.
What occurred during his presidency that led to the breakdown in the American political process? Of course a Republican Congress did not help. But in the end Mr. Obama failed to provide firm political leadership experienced and supported by the American electorate.
His leadership style can best be described as "leading from behind." This is a style perhaps suited to a university president but not to the president of the United States. The victory of Donald Trump is its political renunciation.
SIDNEY WEISSMAN
Chicago
To the Editor:
Barack Obama, because of his superior character, in combination with a deep respect for the office, has chosen to refrain from fanning the widespread flames of fear, incredulity and anger framing a Donald Trump presidency.
President Obama's oratorical skills, paired with a keen intellect enabling him to digest complex issues, have served to establish his credibility as leader of the world's most visible country.
Economic indicators have risen dramatically during Mr. Obama's tenure. More Americans have health care coverage than ever before as a result of the Affordable Care Act. Mr. Obama has been at the forefront of a global initiative to address climate change.
Frustrated by the seemingly insurmountable mountain of resistance blocking gun control legislation, the president has nonetheless demonstrated an ability to empathetically connect emotionally with the victims of gun violence.
Though weathered by the storm, President Obama bequeaths a legacy of hope for the current and future generations.
ROBERT JUDKINS
Hendersonville, Tenn.
LOAD-DATE: January 19, 2017
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(First Draft)
January 23, 2016 Saturday
'Hillarycare' Failed, But Hillary Clinton Reminds Voters She Tried
BYLINE: AMY CHOZICK
SECTION: US; politics
LENGTH: 339 words
HIGHLIGHT: While criticizing Senator Bernie Sanders’ universal health care plan as impractical, Hillary Clinton is reminding voters she tried something similar during her husband’s first term.
After weeks of criticizing Bernie Sanders's plan for a single-payer "Medicare for all" health care system as budget busting and unrealistic, Hillary Clinton over the past few days has a new message for voters: Universal health care was her idea first.
"Now, before it was called Obamacare, it was called Hillarycare, as some of you might remember," Mrs. Clinton said at a town-hall-style event in Clinton, Iowa, on Saturday, the second time in recent days she has used the line.
"We share the same goal, universal health care for every single American," Mrs. Clinton said of her rival Mr. Sanders. "But we have a real difference about how to get there."
Health care has become a major point of contention between Mrs. Clinton and Mr. Sanders, who are fighting to come out ahead in the Feb. 1 caucuses. Mr. Sanders's plan would require over a trillion dollars a year paid for with a broad set of new taxes. His campaign says the plan would save middle-class families money on co-pays and deductibles despite the tax increase. Mrs. Clinton has hit Mr. Sanders for wanting to scrap President Obama's signature domestic achievement and raise taxes on the middle class. She has promised to improve on the Affordable Care Act.
The strategy of reminding voters that she was at the forefront of pushing for universal health care could help Mrs. Clinton appear more authentic as she tries to compete with a populist liberal candidate who identifies as a Democratic socialist. But the new line in her stump speech could also evoke a tumultuous period during President Bill Clinton's administration when the first lady was tasked with overhauling the health care system - and ultimately failed. Her proposals at the time aimed to provide universal health care, though they would have made employers responsible for their workers' insurance, while Mr. Sanders envisions a government-run system.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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The New York Times
February 1, 2014 Saturday
Late Edition - Final
After Meeting, Republicans Seem Unsure of Way Forward
BYLINE: By JONATHAN WEISMAN
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 685 words
CAMBRIDGE, Md. -- House Republicans ended a three-day retreat here united in their division. They agreed they wanted to ''go big'' with a midterm election agenda that would give voters a clear choice, and not simply be a campaign focused on their criticism of President Obama.
''How else do you project a bold alternative option for the country?'' asked Representative Jim Jordan of Ohio, an influential conservative.
At that point, things became less clear. They could not coalesce around their approach on overhauling the immigration laws, increasing the nation's borrowing limit, providing an alternative to the Affordable Care Act or whether to press forward with a rewrite of the tax code.
House Republican leaders had cautioned that final decisions were not likely to be made at the conference, and they were right. One House Republican conceded ideas were ''all over the map.''
''Still some work to do here,'' said Representative Reid Ribble, Republican of Wisconsin, after a lengthy discussion of the impending debt-ceiling showdown.
Representative Eric Cantor of Virginia, the House majority leader, did promise a vote on a health care alternative this year, the closest thing to a decision. Yet House members say he left it unclear whether the vote would be on a full-scale replacement for the health care law, or a less comprehensive measure.
On the debt ceiling, there was movement even if it stopped short of a decision, as some of the House's most ardent conservatives signaled they were ready go along with their leadership and avoid a default. This represents a change of position for many Republicans who, since 2011, have maintained that freezing the debt limit would not bring the economic disaster most economists foresee. Doug Holtz-Eakin, a Republican economist and a former Congressional Budget Office director, opened the session with an explanation of why Congress must raise the borrowing threshold.
If Republicans want to extract even minor concessions, they will have to move soon, within the next seven to 10 days, aides said, because attaching any conditions will precipitate a fight with the Senate with fewer than 28 days until default. But no deadline was set.
Democrats, led by Treasury Secretary Jacob J. Lew, have held firm that they will not accept any concessions attached to a debt-limit increase.
''The more time Republicans spend dreaming up their latest debt limit wish list, the closer they are pushing workers and the economy toward another completely unnecessary crisis,'' said Senator Patty Murray, Democrat of Washington. ''The American people are sick and tired of Republicans playing games with our economic recovery, and Democrats have made it clear that Republicans don't get to demand a ransom simply for allowing Congress to do its job.''
Republicans do appear ready to coalesce around legislation to repeal the Affordable Care Act and replace it with a Republican alternative, despite concerns that such legislation will give Democrats a chance to go on the offensive over health care.
Senators Tom Coburn of Oklahoma, Orrin Hatch of Utah and Richard Burr of North Carolina released their alternative framework on Monday, which emphasizes having patients assume more out-of-pocket costs to encourage more cautious health care consumption, allows businesses to band together to bargain for lower-cost insurance, caps the employer tax deduction for health care and relaxes coverage requirements in the president's law.
Democrats immediately attacked the plan for allowing substandard insurance policies and leaving many people with pre-existing conditions unprotected.
Mr. Burr stood by the effort in the face of some Republican criticism that the party should focus on criticizing the president's law, not diluting the line of attack by producing an alternative.
''There are many Republican members that felt just having a target was a pretty good election year issue,'' Mr. Burr said. ''For Orrin and Tom and I, we're policy wonks. We believe that if you wait another year to start this debate about alternatives, you've done so much damage, some of it will be irreparable.''
URL: http://www.nytimes.com/2014/02/01/us/politics/conference-offers-no-clear-path-forward-for-house-republicans.html
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The New York Times
February 1, 2015 Sunday
Late Edition - Final
White House Seeks to Limit Health Law's Tax Troubles
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 971 words
WASHINGTON -- Obama administration officials and other supporters of the Affordable Care Act say they worry that the tax-filing season will generate new anger as uninsured consumers learn that they must pay tax penalties and as many people struggle with complex forms needed to justify tax credits they received in 2014 to pay for health insurance.
The White House has already granted some exemptions and is considering more to avoid a political firestorm.
Mark J. Mazur, the assistant Treasury secretary for tax policy, said up to six million taxpayers would have to ''pay a fee this year because they made a choice not to obtain health care coverage that they could have afforded.''
But Christine Speidel, a tax lawyer at Vermont Legal Aid, said: ''A lot of people do not feel that health insurance plans in the marketplace were affordable to them, even with subsidies. Some went without coverage and will therefore be subject to penalties.''
The penalties, approaching 1 percent of income for some households, are supposed to be paid with income taxes due April 15. In addition, officials said, many people with subsidized coverage purchased through the new public insurance exchanges will need to repay some of the subsidies because they received more than they were entitled to.
More than 6.5 million people had insurance through the exchanges at some point last year, and 85 percent of them qualified for financial assistance, in the form of tax credits, to lower their premiums. Most people chose to have the subsidies paid in advance, based on projected income for 2014. If their actual income was higher -- because they got a raise or found a new job -- they will be entitled to a smaller subsidy and must repay the difference, subject to certain limits.
''If the advanced premium tax credit amount is too high, the taxpayer could have an unwelcome surprise and owe money,'' said Nina E. Olson, the national taxpayer advocate at the Internal Revenue Service.
Many people awarded insurance subsidies for 2014 did not realize that the amount would be reviewed and recalculated at tax time in 2015.
Consumers are sure to have questions, but cannot expect much help from the tax agency, where officials said customer service had been curtailed because of budget cuts.
The 2015 filing season could be the most difficult in decades, officials said. Ms. Olson said new paperwork resulting from the Affordable Care Act would probably exacerbate problems with customer service, which ''has reached unacceptably low levels and is getting worse.''
''The I.R.S. is unlikely to answer even half the telephone calls it receives,'' she added. ''Taxpayers who manage to get through are expected to wait on hold for 30 minutes on average and considerably longer at peak times.''
Timothy S. Jost, an expert on health law at the Washington and Lee University School of Law who supports the Affordable Care Act, said: ''It will be very easy to find people who are unhappy with the new tax obligations -- people who have to pay a penalty, who have to wait forever to get through to somebody at the I.R.S. or have to pay back a lot of money because of overpayments of premium tax credits.''
Taxpayers normally report income and compute taxes annually. But the health care law is different. Consumers may be subject to tax penalties for any month in which they had neither insurance coverage nor an exemption.
The calculations will be relatively simple if all members of a household had coverage for every month of 2014. They can simply check a box on their tax return. But lower-income people often have changes in employment, income and insurance. If any members of a household were uninsured in 2014, they must fill out a work sheet showing coverage month by month, and they may owe penalties.
To claim tax credits, consumers need to fill out I.R.S. Form 8962, which includes a matrix with 12 rows and six columns -- a total of 72 boxes, to compute subsidies for each month. Most taxpayers use software to prepare returns, and that will simplify the process, officials said.
Federal officials have authorized more than 30 types of exemptions from the penalty for not having insurance. One is for low-income people who live in states that did not expand Medicaid. Another is available to people who would have to pay premiums amounting to more than 8 percent of their household income. The government will also allow a variety of hardship exemptions and in most cases will require taxpayers to send in documents as evidence of hardship.
The open enrollment period, during which people can sign up for health insurance in the public markets and avoid future penalties, ends on Feb. 15. But many people will not realize that they must have coverage or pay a penalty until they file their tax returns in April.
Obama administration officials said they were considering a ''special enrollment period'' that would give some people extra time to obtain insurance. But they said consumers could not count on an extension of the Feb. 15 deadline and should not delay signing up.
Health plans are classified in five categories, such as gold, silver and bronze, based on how generous the coverage is. To calculate their tax credits, consumers need to know the cost of their own policies, but must also know the cost of a benchmark plan, the second-lowest-cost silver plan. To claim an exemption if the available coverage was unaffordable, they also need to know the premium for the lowest-cost bronze plan in the area in 2014.
Sylvia Mathews Burwell, the secretary of health and human services secretary, said the administration was working with nonprofit groups like AARP and tax preparation companies like H&R Block and Intuit, the maker of TurboTax software, to help people meet their tax obligations under the health care law.
URL: http://www.nytimes.com/2015/02/01/us/politics/white-house-seeks-to-limit-health-laws-tax-troubles.html
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GRAPHIC: PHOTO: Paulette Sheffield, left, of the Leadership Council for Health Communities in Washington, helping a client find insurance. (PHOTOGRAPH BY JONATHAN ERNST/REUTERS)
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September 24, 2014 Wednesday
Late Edition - Final
25 Percent Increase in Insurers on Health Marketplaces Is Predicted for Next Year
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 585 words
WASHINGTON -- Consumers in much of the country will have a broader selection of health insurance plans next year, the Obama administration said Tuesday, as it predicted an increase of about 25 percent in the number of insurers that are expected to compete in federal and state marketplaces.
More competition will help hold down premiums, federal health officials said. The administration released preliminary data on insurers that have indicated they want to participate next year in the insurance exchanges, where the federal government subsidizes premiums for millions of people.
So far, it said, the number of insurers, also known as issuers, is up to 315 next year, from 252 this year. For the 36 states served by the federal marketplace, it said, the number is up almost 30 percent, to 248 next year, from 191 this year.
Fourteen states ran their own exchanges, and half have reported the number of insurers expected in 2015. The number in these states and the District of Columbia is expected to increase by about 10 percent, to 67, from 61, the administration said. A three-month open-enrollment period begins Nov. 15.
Sylvia Mathews Burwell, the secretary of health and human services, disclosed the numbers of insurers in a speech at the Brookings Institution, where she said the data showed that ''the Affordable Care Act is working.''
''During the last open enrollment,'' she said, ''consumers could choose from an average of nearly 50 plans. Today, we're able to announce that in 2015 there will be a 25 percent increase in the total number of issuers selling health insurance plans in the marketplace.''
The numbers are generally consistent with reports by some insurers, which have said they are moving into additional states because they see the government-subsidized market as a business opportunity.
However, the numbers came with several qualifications.
Many states have more than one insurance market or rating area. An insurer is counted as participating in a state if it is in just one local market. Consumers in an urban area may have additional choices next year, but that does not guarantee the same options for people in rural areas who had more limited choices this year. The administration did not disclose the number of plans in each rating area in a state.
Moreover, administration officials said, if an insurer offers its products on the exchanges of three states, that is counted as three insurers.
The numbers, through Sept. 4, do not reflect a decision last week by PreferredOne, the largest provider of coverage on Minnesota's insurance exchange, to pull out of the state's online marketplace.
Federal officials said they were pleased to see increases in states with few options this year. In New Hampshire and West Virginia, the federal exchange had just one private insurer this year, officials said. The number is expected to increase to five in New Hampshire and two in West Virginia.
Likewise, officials said, in Alabama, Maine, Mississippi and North Carolina, the number of insurers will rise to three in 2015, from two this year. In Alaska and Wyoming, the number will remain at two.
In Arkansas and Montana, officials said, the number of insurers on the federal exchange will rise to four, from three this year. The number will be unchanged at three in Delaware, North Dakota and South Dakota.
Among the states showing substantial increases were Indiana, where the number of insurers is rising to nine, from four, and Missouri, where the number is doubling, to eight, officials said.
URL: http://www.nytimes.com/2014/09/24/us/under-affordable-care-act-25-percent-increase-in-health-insurers-is-predicted.html
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The New York Times Blogs
(You're the Boss)
October 10, 2013 Thursday
Following Up on Our Sales Training, Profit-Sharing, Health Insurance and the Shutdown
BYLINE: PAUL DOWNS
SECTION: BUSINESS; smallbusiness
LENGTH: 721 words
HIGHLIGHT: The good news: We just had our best month ever. The bad news: We can’t get paid for our work for the federal government.
I usually pick one thing that has happened to me recently to write about, but the reality of life as a boss is that a typical day, week, or month consists of a series of unrelated events. They don't always fit together into a neat narrative with a clear theme.
Last week was a good example. A bunch of stuff happened - both good news and bad news - and I'm not sure what it all means. Can you help me make sense of these events?
Last month, we booked more work than ever before, 22 orders totaling $460,984. Our target for each month is $200,000. We're also ahead of my target for the year, with new orders totaling $2.3 million as of Oct. 8. My target for the year was $2.4 million, which was a 20-percent bump from last year's orders. We're going to pass that easily - all of which suggests our sales training paid off.
I hired two workers earlier this year, raising our staff from 15 to 17, and I will probably add at least one more person before the year ends. These are full-time, well paid jobs with benefits.
We just completed our second quarter with the new profit-sharing scheme, and I'll be paying out another sizable bonus. Our results for the quarter: $93,166 in profits on $688,689 in revenue. Thirty percent of the profit goes into the bonus pool. So far, I'd say that the program is performing as intended. And after I announced the payout yesterday, everyone thanked me!
Last week, I handed out notices to my workers about the existence of the new health insurance exchanges, as mandated by the Affordable Care Act. I'm pretty sure that, since I have fewer than 50 workers, I don't have to do anything more. We already offer insurance, and everyone is either on our plan or a spouse's plan - everyone except for my lowest paid worker. He has been with me since the winter but didn't sign up for our plan, probably because he couldn't afford it. I gave him a raise sufficient to buy insurance for himself and his wife, just so that I can sleep at night.
Out of curiosity, I tried to find more information about the small-business exchanges that I've been hearing about, but didn't have much luck. Nothing online yet. I have already received a notice from our insurer, Independence Blue Cross, that our existing plans are going to disappear and be replaced with something that conforms to the "Obamacare" plans, but I'm not sure which metal level we will end up in. We generally get our health insurance renewal package in mid-November, and I guess I'll sit tight until then.
Meanwhile, the government shutdown has been annoying. The sequester didn't slow our business with the government - we have booked $258,145 in orders from various branches of the federal government this year, which is an increase over last year. But the timing of the shutdown is having a significant effect on my cash flow.
We shipped a very large order, worth more than $100,000, to a NASA facility at the end of September. It was supposed to be installed this week, which meant that I would get my money early next month. (We take federal orders on a net-30 basis, so I did that job without any payment up front, which is not our usual practice.)
Now the delivery is delayed until the Republicans come to their senses. It's not a serious problem for us, yet, but I would be much happier knowing that my money is on its way. I wonder whether all of those people complaining about government spending actually understand what happens to that money. When I get paid by the government for work I have done, I don't take the cash and burn it at a little altar to Karl Marx. Instead, I pay it out to my workers, my suppliers, my landlord, and whoever else sells things to me. A dollar spent by the government isn't destroyed. It goes back into circulation and helps keep companies like mine going strong.
Those of you who claim to be on the side of small businesses, listen to me: get the government back up and running. I need my money.
So that was my week. How was yours?
Paul Downs founded Paul Downs Cabinetmakers in 1986. It is based outside Philadelphia.
Why Labeling Health Plans Gold, Silver or Bronze Doesn't Help
What Does the Affordable Care Act Mean for Your Business?
A Health Insurance Offer for the Busy Start-Up
Business Owners Say They Have Yet to Figure Out Health Care
Employer Mandate, Delayed by Paperwork (and Efforts to Reduce It)
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The New York Times
February 11, 2015 Wednesday
Late Edition - Final
Complicated Politics of Medicaid Expansion Are Playing Out State by State
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 826 words
WASHINGTON -- In Pennsylvania, Gov. Tom Wolf, a newly elected Democrat, is scrapping his Republican predecessor's conservative approach to expanding Medicaid under the Affordable Care Act. Mr. Wolf said this week that he would instead pursue a straightforward expansion of the government health insurance program for the poor, no longer charging premiums or limiting benefits for some enrollees.
In Tennessee and Wyoming, however, bills to extend Medicaid to far more low-income residents under the law were quashed by Republican legislators last week, despite having the support of the states' Republican governors. Opponents in both states said that, among other things, they did not believe the federal government would keep its promise of paying at least 90 percent of the cost of expanding the program. It currently pays the full cost, but the law reduces the federal share to 90 percent -- a permanent obligation, it says -- by 2020.
''I learned that some feelings about the federal government here run deeper than practical economics,'' said State Senator Michael Von Flatern of Wyoming, a Republican who sponsored the Medicaid expansion bill that failed there on Friday.
Next up is Utah, where Gov. Gary R. Herbert, also a Republican, has negotiated a tentative deal with the Obama administration for an alternative Medicaid expansion but is meeting with resistance in his state's Republican-controlled Legislature. Legislators started discussing the bill this week, along with a scaled-back version offered by Republicans in the State House of Representatives, and may vote soon on whether to expand the program.
These new developments underscore just how complicated the politics of expanding Medicaid have become -- and just how different the results of seeking an expansion have been from state to state.
So far, 28 states have taken advantage of the federal funds offered through the health care law to sharply increase the number of adults eligible for Medicaid. Ten had Republican governors when they decided to expand the program, and supporters of the law hoped that the most recent, Indiana, would influence other holdouts to follow.
Indiana's governor, Mike Pence, is a high-profile conservative who nonetheless decided that accepting the federal Medicaid expansion funds -- albeit with concessions from the Obama administration, like requiring many beneficiaries to pay something toward their coverage or be locked out of it for six months -- was good policy.
But barely a week after Mr. Pence announced he was moving ahead with his version of Medicaid expansion, a similar plan from Gov. Bill Haslam of Tennessee suffered a swift defeat at the hands of a State Senate committee, seemingly extinguishing any hope of expanding the program there for now.
Mr. Haslam had called a special session for the Legislature to consider his plan, which he had spent months working out with the Obama administration. He had traveled the state to promote it -- and to try to persuade people that it was not part and parcel of the Affordable Care Act, partly because the Tennessee Hospital Association had agreed to pay any expansion costs beyond what the federal government covered. On Feb. 2, as the special session opened, he appealed to legislators to ''look past the easy political argument'' and agree to expand Medicaid to some 280,000 uninsured residents of Tennessee.
Less than 48 hours later, his plan was dead after a Senate committee dominated by Republicans rejected it before it could reach the full chamber.
''It was a little embarrassing to do all that and come away with nothing,'' Mr. Haslam told reporters in Nashville on Thursday.
Tennessee's chapter of Americans for Prosperity, the Tea Party-affiliated group backed by Charles G. and David H. Koch, and the Beacon Center of Tennessee, a Nashville nonprofit that advocates smaller government, urged the Legislature to scuttle the governor's plan.
Other Republican-controlled state legislatures may well consider Medicaid expansion in the coming months, although passage is far from certain. In Florida, business leaders and hospital executives are pressuring conservative legislative leaders to consider alternative expansion plans in the session that starts next month. And in Alaska, the new governor, Bill Walker, an independent, wants to persuade state lawmakers to agree to expand Medicaid by the start of the new fiscal year on July 1.
In Idaho, an alternative Medicaid expansion plan, put forth by a task force appointed by Gov. C. L. Otter may go before the Legislature in the next few months.
Still, Senator Von Flatern of Wyoming said he believed efforts to expand the program in Republican states may stall after the defeats in his state and in Tennessee.
''The argument is that the federal government is already in debt and expanding Medicaid will make it worse,'' he said. ''I would say that over all, no -- you won't see much more expansion.''
URL: http://www.nytimes.com/2015/02/11/us/complicated-politics-of-medicaid-expansion-are-playing-out-state-by-state.html
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(The Caucus)
June 12, 2012 Tuesday
Now Who's Out of Touch? Romney Tries to Turn the Tables on Obama
BYLINE: MICHAEL BARBARO
SECTION: US; politics
LENGTH: 889 words
HIGHLIGHT: For the fifth day in a row, the Romney campaign assailed President Obama for remarks that he said revealed the president's disconnect from economic reality.
ORLANDO, Fla. - Mitt Romney understands the power of the verbal gaffe, real or perceived. During the Republican primaries, he offered up an all-you-can-eat buffet of them: his wife's "Cadillacs," his friends' Nascar teams, how he liked being able to fire people.
Every time, the Obama campaign and its Democratic allies were eager to pounce.
Now, having absorbed the painful lessons of the hyper-magnified (and context-removed) political blunder, Mr. Romney is turning the tables on President Obama.
For the fifth day in a row, the Romney campaign assailed Mr. Obama on Tuesday over remarks that it said revealed his disconnect from economic reality, a theme that began on Friday after the president declared that the "private sector is doing fine" and shows no signs of letting up.
In a speech here in Orlando, Mr. Romney seized on a statement that the president made on Monday about the Affordable Care Act.
In an interview, a television reporter had asked the president about a small business in Iowa, whose owner claimed that the president's health care legislation had contributed to its closing in the state. Mr. Obama said that such an assertion of cause and effect was "kind of hard to explain."
"Because the only folks that have been impacted in terms of the health care bill are insurance companies who are required to make sure that they're providing preventive care, or they're not dropping your coverage when you get sick," Mr. Obama said. "And so, this particular company probably wouldn't have been impacted by that."
A gaffe? Mr. Romney treated it that way, and in his speech at a factory that makes air filters, he called the statement "something else that shows just how much out of touch" the president is.
"He said he didn't understand that Obamacare was hurting small business," Mr. Romney said. "You have to scratch your head about that."
Mr. Romney cited an online survey of almost 1,500 small-business owners, performed last July for the U.S. Chamber of Commerce, which found that three-quarters of them said they would be less likely to hire because of the burdens of the Affordable Care Act.
Afterword, a senior adviser to Mr. Romney, Eric Fehrnstrom, said that Mr. Obama's comments about health care showed that "this is a president who is detached from the effect his policies are having on the economy."
The charge of being out of touch is as old as politics itself. But it has become clear that the strategy will be deployed with growing regularity by the Romney campaign, allowing it to cast Mr. Obama as an entrenched Washington insider and sidestep potentially nettlesome issues like Mr. Romney's own experience with health care in Massachusetts. Not once during his speech on Tuesday did Mr. Romney discuss his government-sponsored overhaul of that state's health care system.
Instead, Mr. Romney reiterated his plan to replace the Affordable Care Act with what he likened to a "consumer market." That plan would allow those who buy insurance to receive the same tax advantages as businesses that purchase insurance for employees, ensure coverage for those with pre-existing conditions and hand control of health care to states, rather than the federal government.
With the Supreme Court likely to rule soon on the constitutionality of the health care law, Mr. Romney emphasized that his plan would be put into place regardless of the court's decision.
The Romney campaign has a simple message these days, which it is repeating over and over: what it portrays as President Obama's "mistakes" are not mistakes at all. Instead, they are windows into the mind of a man detached from the problems of ordinary Americans and small businesses.
It is a striking line of attack that seeks to repurpose and reverse the thrust of Mr. Obama's central critique of Mr. Romney: that he is a rapacious corporate raider unfamiliar with the problems of regular Americans.
That message was at the core of the television commercials that the Obama campaign has run mocking Mr. Romney's tenure at Bain Capital, which feature laid-off workers. And at a fund-raiser in Owings Mills, Md., on Tuesday, Mr. Obama, who plans to give an address on the economy on Thursday, chided his opponent for his barrage of recent attacks.
"Because folks are still hurting right now, the other side feels that it's enough for them to just sit back and say things aren't as good as they should be, and it's Obama's fault," the president said. "I mean, you can pretty much put their campaign on a tweet and have some characters to spare."
The president's campaign staff said it welcomed a debate over which candidate is more out of touch, especially given Mr. Romney's rhetorical record during the primary. But that is not deterring Mr. Romney. On Tuesday morning, he appeared on "Fox and Friends," where he said the president was "really out of touch with what is happening across America."
"The president needs to go out and talk to people, not just do fund-raisers, go out and talk to people in the country and find out what is happening," Mr. Romney said.
That criticism appears to be seeping in. At the event here, Frank Attkisson, a small-business consultant and local commissioner, nodded in agreement with Mr. Romney during the speech, and afterword said the president's statements about the private sector and the health care law reveal "his true colors."
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The New York Times
October 8, 2013 Tuesday
Late Edition - Final
The Plotting Before the Shutdown
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 26
LENGTH: 667 words
To the Editor:
Re ''A Crisis Months in the Planning'' (front page, Oct. 6):
It is unconscionable that we continue to permit propaganda barons to manipulate our Congress and sabotage the functioning of our government. With potentially bottomless pockets, these spoilers could wage their private war against any piece of legislation they don't like with endless skirmishes that not only defy the will of the people but also distract from the serious problem-solving in which our nation must engage.
This is a bad way to run our democracy.
JONATHAN BIATCH Madison, Wis., Oct. 6, 2013
To the Editor:
''A Crisis Months in the Planning'' reads like news coverage of a plot to overthrow the United States government schemed up in some dark alley in a foreign land. Or to overthrow part of it anyway -- the Affordable Care Act.
The act, ratified by duly elected representatives of the American people, signed into law by our (now twice-elected) president, and upheld by the Supreme Court, is now the law of the land. Yet a cabal of well-financed individuals lacking the legislative power to overturn the act has striven to overrule the will of the people and hatched a plot to kill this statute by whatever means necessary.
The government shutdown orchestrated by Republican representatives and their conspirators reflects a contempt for our democratic process and constitutes a complete abrogation of their responsibility to support and defend the Constitution.
KENNETH N. GIEDD New York, Oct. 6, 2013
The writer is a cardiologist.
To the Editor:
In 2009, the nonpartisan Institute of Medicine reported that 45.7 million American residents without health insurance experienced greater disability and death from stroke, cardiac disease, cancer and events requiring hospitalization. A study in The American Journal of Public Health that year estimated that this uninsured population suffers 45,000 excess preventable deaths each year.
The Affordable Care Act's extension of health insurance to the uninsured reflects two bioethical principles that should guide health providers: beneficence (promote health) and justice (distribute health resources fairly). The ideologues who aim to defund the act may say they are defending a third bioethical principle, individual autonomy: the right to say ''no'' as well as ''yes'' to health interventions.
If they succeed, however, their narrow notion of liberty will destroy the autonomous right of millions of fellow Americans to choose health insurance, better access to medical care and longer survival.
FREDERICK A. SMITH Garden City, N.Y., Oct. 6, 2013
The writer is an internist and a clinical bioethicist at the North Shore-L.I.J. Health System.
To the Editor:
The conservative activists David Koch, Michael A. Needham and Edwin Meese III are merely members of the losing team who refuse to clear the field months after a thumping defeat. They, and those who follow them, are whiners.
Numbers matter. The votes were tallied. They lost. Badly. We can all revisit the situation in November 2014.
D. C. MONTAGUE Chattanooga, Tenn., Oct. 6, 2013
To the Editor:
Re ''Boehner Hews to Hard Line in Demanding Concessions From Obama'' (news article, Oct. 7):
''There are not the votes in the House to pass a clean C.R.,'' says Speaker John A. Boehner, referring to a continuing resolution to provide money for military and domestic programs. To which I think a majority of Americans would reply: ''Put our money where your mouth is. Call for the vote.''
BILL SWEENEY Shorewood, Wis., Oct. 7, 2013
To the Editor:
Re ''In Rural Iowa, Spending, Not the Shutdown, Raises Worry,'' by James B. Stewart (Common Sense column, front page, Oct. 5):
Many of Representative Steve King's constituents see the government shutdown as a way to distinguish between essential and nonessential services. Just as an alcoholic is someone who drinks more than you and a minor operation is someone else's, so, perhaps, nonessential services are those that you and your family don't need.
STEVEN BERKOWITZ New York, Oct. 5, 2013
URL: http://www.nytimes.com/2013/10/08/opinion/the-plotting-before-the-shutdown.html
LOAD-DATE: October 8, 2013
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PUBLICATION-TYPE: Newspaper
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The New York Times Blogs
(Bucks)
July 10, 2013 Wednesday
Computer Snag Limits Insurance Penalties on Smokers
BYLINE: ANN CARRNS
SECTION: YOUR-MONEY
LENGTH: 699 words
HIGHLIGHT: A software glitch involving the new health care law may mean that some smokers won’t bear the full brunt of tobacco-user penalties that could have made their premiums much higher, at least for the first year.
A computer glitch involving the new health care law may mean that some smokers won't bear the full brunt of tobacco-user penalties that would have made their premiums much higher - at least, not for next year.
The Obama administration has quietly notified insurers that a computer system problem will limit penalties that the law says the companies may charge smokers, The Associated Press reported Tuesday. A fix will take at least a year.
The problem relates to the computer system where insurers submit their "qualified" health plans to be offered on the new exchanges where individual insurance plans will be sold beginning Oct. 1.
"This is a temporary circumstance that in no way impacts our ability to open the marketplaces on Oct. 1, when millions of Americans will be able to purchase quality, affordable insurance for the first time," said Joanne Peters, a spokeswoman for the Department of Health and Human Services, in an e-mailed statement.
Starting in 2014, the law requires insurance companies to accept all applicants regardless of pre-existing medical problems. But it also allows them to charge smokers up to 50 percent higher premiums to ward off bad risks. For an older smoker, the cost of the full penalty could be prohibitive.
The underlying reason for the glitch is another provision in the health care law that says insurers can't charge older customers more than three times what they charge the youngest adults in the pool.
According to a June 28 guidance from the government to insurers quoted by The A.P., "Because of a system limitation ... the system currently cannot process a premium for a 65-year-old smoker that is ... more than three times the premium of a 21-year-old smoker," the guidance said. If an insurer tries to charge more, "the submission of the (insurer) will be rejected by the system," it added.
Ms. Peters said in her statement that the problem is temporary. For 2014 only, "tobacco ratings across age groups cannot produce premiums that are more than a three-to-one ratio," she said. "In 2015 and beyond, the system will expand to allow issuers to increase this ratio, if they choose to do so."
Older smokers are more likely to benefit from the delay, experts say. But depending on how insurers respond to it, it's also possible that younger smokers could wind up facing higher penalties than they otherwise would have.
The glitch could mean that insurers could charge all smokers the maximum allowable surcharge to get around the ratio problem, which would end up penalizing younger smokers with higher penalties than they might otherwise have received. But it is unclear what insurers will do.
"'We are aware of the issue," said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, an insurance industry group. "But I can't speak to how insurers will respond to it."
He said he was unaware of any estimates of how many people would be affected by the law's insurance smoker surcharges.
Premiums for a standard "silver" insurance plan would be about $9,000 a year for a 64-year-old nonsmoker, according to the online Kaiser Health Reform Subsidy Calculator. That's before any tax credits, available on a sliding scale based on income.
For a smoker of the same age, the full 50 percent penalty would add more than $4,500 to the cost of the policy, bringing it to nearly $13,600. And new tax credits available to help pay premiums cannot be used to offset the penalty.
The administration is suggesting that insurers limit the penalties across all age groups. The guidance document from the Department of Health and Human Services used the example of a 20 percent penalty for young and old alike.
In that case, the premium for a 64-year-old would be about $10,900, a significant cut from the $13,600 if insurers charged the full penalty.
Workers covered through job-based health plans would be able to avoid tobacco penalties by joining smoking cessation programs, because employer plans operate under different rules.
Family Medical Costs Still Rising
About Half of Adults Lacked Adequate Health Coverage in 2012
Shorter Forms for Coverage Under New Health Law
Breast Pump Coverage Under New Law Varies In Practice
Finding Unclaimed Assets, for a Fee
LOAD-DATE: July 10, 2013
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921 of 1000 DOCUMENTS
The New York Times Blogs
(Fiscal Crisis)
October 2, 2013 Wednesday
Report: Shutdown Could Make Budget Deficit Worse
BYLINE: Gerry Mullany
SECTION: US; politics
LENGTH: 189 words
HIGHLIGHT: A Wall Street report says warns of “upside risk” to the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands.
At first blush, it might seem that a government shutdown would have a positive effect on the budget deficit, reducing its growth by constraining spending. But not so fast.
A BofA Merrill Lynch Global Research report says that the shutdown is likely to "put upside risk" on the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands:
"Inside the Beltway this may look like a 'zero-sum game' where one party's win is the other party's loss. However, outside the Beltway, we believe this is very much a negative-sum game: the odds of a major shock to the economy and a full-blown correction to the stock market have risen.
Ironically, we think this also puts upside risk to the budget deficit - due to shutdown costs and reduced revenues - and it does not slow implementation of the Affordable Care Act - it is funded outside of the appropriations process."
Missing Out on History in Boston
Utah Senator Causes Uproar Among House Republicans
Senate Cancels First Hearing on Navy Yard Shooting
Republicans and Democrats Look for Compromise
Senate Rejects House Bill and Sends It Back
LOAD-DATE: October 2, 2013
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922 of 1000 DOCUMENTS
The New York Times Blogs
(Fiscal Crisis)
October 2, 2013 Wednesday
Report: Shutdown Could Make Budget Deficit Worse
BYLINE: Gerry Mullany
SECTION: US; politics
LENGTH: 189 words
HIGHLIGHT: A Wall Street report says warns of “upside risk” to the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands.
At first blush, it might seem that a government shutdown would have a positive effect on the budget deficit, reducing its growth by constraining spending. But not so fast.
A BofA Merrill Lynch Global Research report says that the shutdown is likely to "put upside risk" on the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands:
"Inside the Beltway this may look like a 'zero-sum game' where one party's win is the other party's loss. However, outside the Beltway, we believe this is very much a negative-sum game: the odds of a major shock to the economy and a full-blown correction to the stock market have risen.
Ironically, we think this also puts upside risk to the budget deficit - due to shutdown costs and reduced revenues - and it does not slow implementation of the Affordable Care Act - it is funded outside of the appropriations process."
Missing Out on History in Boston
Utah Senator Causes Uproar Among House Republicans
Senate Cancels First Hearing on Navy Yard Shooting
Republicans and Democrats Look for Compromise
Senate Rejects House Bill and Sends It Back
LOAD-DATE: October 2, 2013
LANGUAGE: ENGLISH
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PUBLICATION-TYPE: Web Blog
Copyright 2013 The News York Times Company
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923 of 1000 DOCUMENTS
The New York Times Blogs
(Fiscal Crisis)
October 2, 2013 Wednesday
Shutdown Could Worsen Budget Deficit, Analysis Says
BYLINE: Gerry Mullany
SECTION: US; politics
LENGTH: 189 words
HIGHLIGHT: A Wall Street report says warns of “upside risk” to the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands.
At first blush, it might seem that a government shutdown would have a positive effect on the budget deficit, reducing its growth by constraining spending. But not so fast.
A BofA Merrill Lynch Global Research report says that the shutdown is likely to "put upside risk" on the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands:
"Inside the Beltway this may look like a 'zero-sum game' where one party's win is the other party's loss. However, outside the Beltway, we believe this is very much a negative-sum game: the odds of a major shock to the economy and a full-blown correction to the stock market have risen.
Ironically, we think this also puts upside risk to the budget deficit - due to shutdown costs and reduced revenues - and it does not slow implementation of the Affordable Care Act - it is funded outside of the appropriations process."
Missing Out on History in Boston
Utah Senator Causes Uproar Among House Republicans
Senate Cancels First Hearing on Navy Yard Shooting
Republicans and Democrats Look for Compromise
Senate Rejects House Bill and Sends It Back
LOAD-DATE: October 2, 2013
LANGUAGE: ENGLISH
DOCUMENT-TYPE: News
PUBLICATION-TYPE: Web Blog
Copyright 2013 The News York Times Company
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924 of 1000 DOCUMENTS
The New York Times Blogs
(Fiscal Crisis)
October 2, 2013 Wednesday
Shutdown Could Worsen Budget Deficit, Analysis Says
BYLINE: Gerry Mullany
SECTION: US; politics
LENGTH: 189 words
HIGHLIGHT: A Wall Street report says warns of “upside risk” to the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands.
At first blush, it might seem that a government shutdown would have a positive effect on the budget deficit, reducing its growth by constraining spending. But not so fast.
A BofA Merrill Lynch Global Research report says that the shutdown is likely to "put upside risk" on the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands:
"Inside the Beltway this may look like a 'zero-sum game' where one party's win is the other party's loss. However, outside the Beltway, we believe this is very much a negative-sum game: the odds of a major shock to the economy and a full-blown correction to the stock market have risen.
Ironically, we think this also puts upside risk to the budget deficit - due to shutdown costs and reduced revenues - and it does not slow implementation of the Affordable Care Act - it is funded outside of the appropriations process."
Missing Out on History in Boston
Utah Senator Causes Uproar Among House Republicans
Senate Cancels First Hearing on Navy Yard Shooting
Republicans and Democrats Look for Compromise
Senate Rejects House Bill and Sends It Back
LOAD-DATE: October 2, 2013
LANGUAGE: ENGLISH
DOCUMENT-TYPE: News
PUBLICATION-TYPE: Web Blog
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925 of 1000 DOCUMENTS
The New York Times Blogs
(Fiscal Crisis)
October 2, 2013 Wednesday
Report: Shutdown Could Make Budget Deficit Worse
BYLINE: Gerry Mullany
SECTION: US; politics
LENGTH: 189 words
HIGHLIGHT: A Wall Street report says warns of “upside risk” to the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands.
At first blush, it might seem that a government shutdown would have a positive effect on the budget deficit, reducing its growth by constraining spending. But not so fast.
A BofA Merrill Lynch Global Research report says that the shutdown is likely to "put upside risk" on the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands:
"Inside the Beltway this may look like a 'zero-sum game' where one party's win is the other party's loss. However, outside the Beltway, we believe this is very much a negative-sum game: the odds of a major shock to the economy and a full-blown correction to the stock market have risen.
Ironically, we think this also puts upside risk to the budget deficit - due to shutdown costs and reduced revenues - and it does not slow implementation of the Affordable Care Act - it is funded outside of the appropriations process."
Missing Out on History in Boston
Utah Senator Causes Uproar Among House Republicans
Senate Cancels First Hearing on Navy Yard Shooting
Republicans and Democrats Look for Compromise
Senate Rejects House Bill and Sends It Back
LOAD-DATE: October 2, 2013
LANGUAGE: ENGLISH
DOCUMENT-TYPE: News
PUBLICATION-TYPE: Web Blog
Copyright 2013 The News York Times Company
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926 of 1000 DOCUMENTS
The New York Times Blogs
(Fiscal Crisis)
October 2, 2013 Wednesday
Shutdown Could Worsen Budget Deficit, Analysis Says
BYLINE: Gerry Mullany
SECTION: US; politics
LENGTH: 189 words
HIGHLIGHT: A Wall Street report says warns of “upside risk” to the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands.
At first blush, it might seem that a government shutdown would have a positive effect on the budget deficit, reducing its growth by constraining spending. But not so fast.
A BofA Merrill Lynch Global Research report says that the shutdown is likely to "put upside risk" on the budget deficit because of the threat it poses to the collection of government revenues, shutdown costs and other demands:
"Inside the Beltway this may look like a 'zero-sum game' where one party's win is the other party's loss. However, outside the Beltway, we believe this is very much a negative-sum game: the odds of a major shock to the economy and a full-blown correction to the stock market have risen.
Ironically, we think this also puts upside risk to the budget deficit - due to shutdown costs and reduced revenues - and it does not slow implementation of the Affordable Care Act - it is funded outside of the appropriations process."
Missing Out on History in Boston
Utah Senator Causes Uproar Among House Republicans
Senate Cancels First Hearing on Navy Yard Shooting
Republicans and Democrats Look for Compromise
Senate Rejects House Bill and Sends It Back
LOAD-DATE: October 2, 2013
LANGUAGE: ENGLISH
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PUBLICATION-TYPE: Web Blog
Copyright 2013 The News York Times Company
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927 of 1000 DOCUMENTS
The New York Times
November 14, 2013 Thursday
Late Edition - Final
With Enrollment Slow, Some Democrats Back Change in Health Law: Only 106,000 Pick Insurance Plans in First Month
BYLINE: By SHERYL GAY STOLBERG and SUSANNE CRAIG; Sheryl Gay Stolberg reported from Washington, and Susanne Craig from New York.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1153 words
WASHINGTON -- Just over 106,000 people picked health plans in the first month of open enrollment through the state and federal insurance marketplaces established by the Affordable Care Act, President Obama's health secretary said Wednesday, a fraction of the administration's initial estimate for enrollment during that period.
Only about a fourth of the new enrollees -- 26,794 -- signed up through HealthCare.gov, the problem-plagued federal exchange, according to figures released by the Centers for Medicare and Medicaid Services. A much larger number, 76,319, signed up through the 14 state-run marketplaces.
The long-awaited figures, released by Kathleen Sebelius, the secretary of health and human services, became instant fodder for the political battle over Mr. Obama's signature legislative initiative. As nervous Democrats on Capitol Hill threatened to introduce legislation altering the law, Republicans called the new numbers dismal and embarrassing, citing them as further proof that the program was a ''train wreck.''
The White House has spent weeks trying to lower expectations about the numbers -- even as questions emerged about the way it counts who is enrolled. On Wednesday, Ms. Sebelius and congressional Democrats were upbeat, saying people were clearly shopping for coverage.
''The marketplace is working,'' Ms. Sebelius said. ''People are enrolling.''
The nonpartisan Congressional Budget Office has predicted seven million people will enroll by the time the initial six-month sign-up window closes, and administration officials insist they can meet that goal. But the numbers released Wednesday fall far short of the administration's early projections, contained in an internal memo in September, which said 464,920 would sign up in the first month.
In a method that Senator Mitch McConnell, the Republican leader, called ''Enron-like accounting,'' the administration defines enrollees as those who have ''selected a marketplace plan.''
They are people like Hung Trang, 60, a nail salon owner in Tampa, Fla., who has been trying for weeks to sign up. With help from a counselor, called a ''navigator,'' he has picked a plan for himself and family, but has not yet committed to buy it.
The industry, though, says people like Mr. Trang do not count until they have agreed to pay.
''Paying the first month's premium is what needs to happen before coverage actually begins,'' said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, the industry trade association. ''Until a consumer makes their first-month premium, they can make a different coverage decision -- including whether they want to buy coverage or not.''
A total of 106,185 consumers went through the enrollment process and picked plans, the administration said. Many more people -- 846,184 -- applied in the state and federal marketplaces without adding plans to their shopping carts for purchase. Those applications would cover a total of 1,509,883 Americans.
A peek into state data reveals vast disparities. Florida, the state with the third-highest number of uninsured (behind California and Texas), had the most enrollees in the federal-run exchange, 3,571. Texas was second, with 2,991. There were just 42 in North Dakota.
In explaining the relatively low figures, administration officials cite problems with the federal website that have prevented people from signing up. But they also say experience shows people wait until the last minute.
When Massachusetts expanded health coverage in 2007, only 123 of the 36,167 people who ultimately signed up did so during the first month of enrollment. But more than 7,000 signed up in the final month. (Massachusetts counted only people who had already paid their premiums as enrollees, according to Jon Kingsdale, who ran that state's health insurance exchange for the first four years.)
There is still one month to go until the Dec. 15 deadline for signing up for coverage that begins Jan. 1; the initial enrollment period does not close until March 31. So administration officials, and some outside experts, say these early figures do not reveal much.
''These numbers are interesting,'' David Simas, a top White House adviser on health care, said in an interview, ''but in terms of any kind of insight into the success of the program, they're not the central indicator.''
In political terms, though, the numbers are yet another problem for the White House, which is one reason Ms. Sebelius -- and not the president -- announced them. Republicans insist that, at this rate, there is no way the administration can reach its goal.
''By the time we reach the critical month of December, actual enrollment could lag projections by over one million people,'' Representative Dave Camp, Republican of Michigan and chairman of the House Ways and Means Committee, wrote in a letter this month, accompanying a subpoena for detailed enrollment data.
In an interview, he said enrollment figures were only a part of the story. ''It's not just about the top-line number,'' he said. ''What I want to know is the mix of these people. What kind of insurance are they getting? What age are they?''
Ms. Sebelius said Wednesday that her agency would release that kind of data at some point; she did not say when. But experts on all sides of the debate agree that the ''mix'' may be far more important than the actual enrollment numbers. If not enough young, healthy people enroll, premiums will skyrocket, and the law's promise of ''affordable care'' will not be realized.
''The mix is valuable for insurers, because it will result in more stable premiums; if all the people who enroll are very sick, they will have to raise premiums next year, and that is a problem,'' said Dan Mendelson, who was a health policy adviser to President Bill Clinton and is now chief executive of Avalere Health, a consulting firm.
''But,'' Mr. Mendelson said, ''the numbers are important; enrollment is important. I do think this administration is going to be benchmarked on how much enrollment materializes.''
Mr. Mendelson's firm recently looked at 12 of the 14 state exchanges and found a far lower rate of enrollment than for other programs, including the expansion of prescription drug coverage under Medicare under President George W. Bush. He said problems with the federal website had created a ''negative communications climate'' that was depressing enrollment.
''Their problem is more than technology,'' he said, referring to the administration. ''It's that because of technology, they can't be beating the drum, and they can't be sending the president out to advocate for enrollment.''
If Massachusetts is any guide, signing up people is difficult even under the best of circumstances, Mr. Kingsdale said. In the first three months of operation, he said, the state found that for each 100 hits on its website, 44 were ''unique hits'' from Massachusetts residents. Of those, 18 shopped for plans, and one bought coverage.
URL: http://www.nytimes.com/2013/11/14/us/health-law-enrollment-figures-far-lower-than-initial-estimates.html
LOAD-DATE: November 14, 2013
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: Insurance agents at a mall in Miami helped people look up what plans were available under the Affordable Care Act last week. (PHOTOGRAPH BY JOE RAEDLE/GETTY IMAGES) (A20) CHART: Health Exchange Enrollment Short of Target: Just over 106,000 people picked a health insurance plan through the state and federal exchanges established under the Affordable Care Act in the first month of open enrollment, a fraction of the 495,000 projected by the Obama administration in a September memo. (Source: Department of Health and Human Services) (CHART BY HAEYOUN PARK/THE NEW YORK TIMES) (A20)
PUBLICATION-TYPE: Newspaper
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The New York Times
January 21, 2013 Monday
Late Edition - Final
The Big Deal
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 21
LENGTH: 804 words
On the day President Obama signed the Affordable Care Act into law, an exuberant Vice President Biden famously pronounced the reform a ''big something deal'' -- except that he didn't use the word ''something.'' And he was right.
In fact, I'd suggest using this phrase to describe the Obama administration as a whole. F.D.R. had his New Deal; well, Mr. Obama has his Big Deal. He hasn't delivered everything his supporters wanted, and at times the survival of his achievements seemed very much in doubt. But if progressives look at where we are as the second term begins, they'll find grounds for a lot of (qualified) satisfaction.
Consider, in particular, three areas: health care, inequality and financial reform.
Health reform is, as Mr. Biden suggested, the centerpiece of the Big Deal. Progressives have been trying to get some form of universal health insurance since the days of Harry Truman; they've finally succeeded.
True, this wasn't the health reform many were looking for. Rather than simply providing health insurance to everyone by extending Medicare to cover the whole population, we've constructed a Rube Goldberg device of regulations and subsidies that will cost more than single-payer and have many more cracks for people to fall through.
But this was what was possible given the political reality -- the power of the insurance industry, the general reluctance of voters with good insurance to accept change. And experience with Romneycare in Massachusetts -- hey, this is a great age for irony -- shows that such a system is indeed workable, and it can provide Americans with a huge improvement in medical and financial security.
What about inequality? On that front, sad to say, the Big Deal falls very far short of the New Deal. Like F.D.R., Mr. Obama took office in a nation marked by huge disparities in income and wealth. But where the New Deal had a revolutionary impact, empowering workers and creating a middle-class society that lasted for 40 years, the Big Deal has been limited to equalizing policies at the margin.
That said, health reform will provide substantial aid to the bottom half of the income distribution, paid for largely through new taxes targeted on the top 1 percent, and the ''fiscal cliff'' deal further raises taxes on the affluent. Over all, 1-percenters will see their after-tax income fall around 6 percent; for the top tenth of a percent, the hit rises to around 9 percent. This will reverse only a fraction of the huge upward redistribution that has taken place since 1980, but it's not trivial.
Finally, there's financial reform. The Dodd-Frank reform bill is often disparaged as toothless, and it's certainly not the kind of dramatic regime change one might have hoped for after runaway bankers brought the world economy to its knees.
Still, if plutocratic rage is any indication, the reform isn't as toothless as all that. And Wall Street put its money where its mouth is. For example, hedge funds strongly favored Mr. Obama in 2008 -- but in 2012 they gave three-quarters of their money to Republicans (and lost).
All in all, then, the Big Deal has been, well, a pretty big deal. But will its achievements last?
Mr. Obama overcame the biggest threat to his legacy simply by winning re-election. But George W. Bush also won re-election, a victory widely heralded as signaling the coming of a permanent conservative majority. So will Mr. Obama's moment of glory prove equally fleeting? I don't think so.
For one thing, the Big Deal's main policy initiatives are already law. This is a contrast with Mr. Bush, who didn't try to privatize Social Security until his second term -- and it turned out that a ''khaki'' election won by posing as the nation's defender against terrorists didn't give him a mandate to dismantle a highly popular program.
And there's another contrast: the Big Deal agenda is, in fact, fairly popular -- and will become more popular once Obamacare goes into effect and people see both its real benefits and the fact that it won't send Grandma to the death panels.
Finally, progressives have the demographic and cultural wind at their backs. Right-wingers flourished for decades by exploiting racial and social divisions -- but that strategy has now turned against them as we become an increasingly diverse, socially liberal nation.
Now, none of what I've just said should be taken as grounds for progressive complacency. The plutocrats may have lost a round, but their wealth and the influence it gives them in a money-driven political system remain. Meanwhile, the deficit scolds (largely financed by those same plutocrats) are still trying to bully Mr. Obama into slashing social programs.
So the story is far from over. Still, maybe progressives -- an ever-worried group -- might want to take a brief break from anxiety and savor their real, if limited, victories.
URL: http://www.nytimes.com/2013/01/21/opinion/krugman-the-big-deal.html
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(You're the Boss)
July 23, 2013 Tuesday
The I.R.S. Interprets the Employer Mandate, and Businesses Have Questions
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1064 words
HIGHLIGHT: The biggest issue in interpreting the new health care law appears to involve how a company determines whether employees whose hours fluctuate must be offered insurance.
As written, the employer mandate in the Affordable Care Act - what the law calls "shared responsibility" - is complicated enough. Just to understand how the penalty applies practically requires a flow chart. But as the Internal Revenue Service has tried to interpret the mandate, the agency and the businesses and employees affected by the mandate are discovering that it is even more challenging than it reads. In some cases, the agency has resolved some of the confusion. But in others, the answers it has come up with have raised still more questions.
The Obama administration this month announced that it was pushing back enforcement of the mandate for a year, to give the I.R.S. time to write the rules on the law's reporting requirements for businesses. But some people hoping to influence the regulations would like to see the agency reconsider some of the other regulations for the mandate it had already proposed. (Others, as we reported earlier, would like to see Congress rewrite the terms of the mandate.)
In the next week or two, The Agenda will take a close look at some of those issues.
The biggest appears to involve how a company determines whether employees whose hours fluctuate must be offered insurance. The Affordable Care Act sets that threshold at 30 hours, which the law deems a full-time schedule. Many companies, though, schedule a fraction of their work force on variable hours: some weeks, or months, a variable-hour employee may work, say, 35 hours; in others, 25 hours. In its preliminary rules, released late last year, the I.R.S. devised an approach to the problem of the variable-hour employee that it calls the "look-back measurement method."
In essence, the proposed regulations would allow an employer to choose a measurement period of three months to a year in which to average the employee's weekly hours. The measurement period would then be followed by a stability period that is at least as long as the measurement period. In practice, said Seth Perretta, an attorney representing several trade groups in the rule making, most employers would likely use a yearlong measurement period running from Oct. 15 through Oct. 14, which would then be followed by open enrollment. The stability period would run the following year.
If an employee's schedule averaged out to full time during the measurement period, then the company would be obliged to offer health insurance in the stability period or pay a penalty. If the worker averaged less than 30 hours a week (or, technically, 130 hours a month), then the company need not offer insurance in the stability period. Either way, a new measurement period would begin immediately after the old one ended, and the process would begin again. (If the company anticipates that a new hire will work full-time, it must offer insurance by the start of the fourth month on the job.)
Some business groups, particularly retail and restaurant groups, worked with agency officials to craft the look-back rule. "I think they understood clearly that in the retail and chain restaurant industries, employees will often not fall into neat full- and part-time categories," said Neil Trautwein, employee benefits policy counsel at the National Retail Federation. "Once you get away from manufacturing, it's not an uncommon problem in the business world."
But what happens when an employee goes from full-time to part-time? J.D. Piro, a senior vice president in charge of the health law group at the benefits consulting company Aon Hewitt, said the rules were unclear. "Do you get to keep your coverage?" he said. "Or do you follow the Cobra rules," which govern what happens when an employee loses health insurance because of a reduction in hours or losing the job? "That's what employers need guidance on - which rules take precedence."
Mr. Perretta, however, said he believed that the I.R.S. had taken the position that the employee would keep the coverage through the end of the stability period. And if it turned out that the worker still managed to average a full-time schedule, which would be possible if he or she made the switch late in the period, the company would have to offer insurance in the next stability period as well or face the penalty. Under this interpretation, then, a full-time employee who switched to part-time in, say, August, would be entitled to an additional 16 months of insurance coverage.
"If you want to avoid the penalty for the folks on the margin who might end up working a full-time schedule, you end up having to assume the complicated machinery for all of the similarly situated" - that is, hourly - "full-time employees," he said. "I think the I.R.S. will try to find other ways that employers can comply with pay or play without having to use as much machinery if they don't want to."
"The stability period is a tough time for employers," said Mr. Trautwein of the retail federation. But, he added, "It's a way of ensuring greater continuity of coverage. It's a problem for employer plans if people are coming and going all the time. It's also a problem for plans in the exchange."
And of course, the issue cuts both ways. Workers who switch to full-time status may have to wait a year or more before the company must offer insurance. Families USA, which supports universal health insurance, argued that this is unfair, since the company must offer coverage to a new full-time employee by the fourth month. "Measurement and stability periods should be used to infer a status of variable-hour employees only," wrote Cheryl Fish-Parcham, the organization's deputy director of health policy, in a comment on the proposed rule. "Once an employee is no longer a variable-hour employee and is in a full-time position, he or she should be offered coverage within, at most, three calendar months."
In other words, there's plenty here for the I.R.S. to think about over the next year. In our next post, we will explore how the I.R.S. and stakeholders representing businesses and workers are wrestling with the employer's obligation to make sure the insurance it offers employees is affordable.
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
A Bakery Is Relieved to Have the Employer Mandate Delayed
Could Employers Use Immigrants to Avoid the Health Mandate?
Bakery Owner Talks About Coping With Health Insurance Changes
Should a Bakery With More Than 50 Employees Offer Health Insurance?
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February 24, 2012 Friday
National Edition
State to Close Program On Federal Health Law
BYLINE: By THANH TAN.
ttan@texastribune.org
SECTION: Section A; Column 0; National Desk; Texas ; THE TEXAS TRIBUNE; Pg. 21A
LENGTH: 625 words
A program created to help insurance-seekers in Texas cut through the complexities of federal health care reforms is shutting down in April, just 15 months after it opened its call center and years before the law goes into full effect.
Officials with the Texas Department of Insurance say they plan to help fill the gap, but it is unclear whether they can handle what some health experts call a beast of a policy change: millions of new patients will be required to acquire health insurance, and those first-time policy holders will need help understanding their rights and benefits.
When President Obama signed the Patient Protection and Affordable Care Act in 2010, a consumer education program was also created. That September, the federal government awarded the Texas Department of Insurance a $2.8 million grant to start the Consumer Health Assistance Program.
As of January, the department reported, the program had answered 8,900 calls and resolved nearly 5,600 cases statewide. A staff of nine employees had dispersed multilingual public service announcements, given field presentations, begun a Web site and staffed a hot line.
State officials say they were allowed to use unspent money to keep those employees on through April 14. But federal financing was not renewed, and unlike some other states, Texas is not seeking alternative means to maintain its program.
Medical officials who are aware of the unit's work lament the timing of its closure, as the Affordable Care Act's rules will not be completely in place until 2018.
In the meantime, health providers are anticipating a nightmare situation. Nearly a quarter of Texas' population is estimated to be uninsured. Unless the United States Supreme Court dismantles parts or all of the law, those people will be required to sign up for benefits beginning in 2014.
''There will be lots of people who've had no experience with insurance before who will need to have a lot of guidance,'' said Regina Rogoff, the chief executive of People's Community Clinic in Austin, a safety net provider. ''They're driving blind.''
Louis J. Goodman, the chief executive of the Texas Medical Association, said doctors were as perplexed as consumers. The federal law is wide in scope, and the association has poured resources into helping practitioners understand the rules and deadlines.
''We've worked on the doctors' side as much as we can,'' Mr. Goodman said, but more consumer education is ''absolutely necessary.''
In the field, he said, overhead costs at clinics could rise because patients increasingly rely on nonmedical staff in their doctor's office to explain benefits.
Processing claims can be tedious. The medical association's Hassle Factor Log, a last resort for doctors trying to resolve claims issues, recovered a record $1.6 million last year for 300 doctors who would have otherwise gone unpaid for their services.
Genevieve Davis, the medical association's payment advocacy director, said she regularly spoke with doctors who complain of spending less time with patients and more time mired in paperwork. And when insurers or employers refuse to cover a service, patients blame their doctors.
''Trying to get patients to understand that takes away from being able to focus on practicing medicine,'' Ms. Davis said.
Health providers say that what separates the assistance program from other insurance resources is that it arms consumers with information on the new health care laws before they walk into a doctor's office.
But John Greeley, a Texas Department of Insurance spokesman, said the tools developed by the program would carry over to a different section in the agency that covers general consumer concerns. He said the department would maintain resources to help people gain access to insurance.
URL: http://www.nytimes.com
LOAD-DATE: February 24, 2012
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GRAPHIC: PHOTO: Explaining insurance rules takes time away from treating patients, Genevieve Davis said. (PHOTOGRAPH BY ERICH SCHLEGEL FOR THE TEXAS TRIBUNE)
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The New York Times
January 14, 2016 Thursday
Late Edition - Final
Clinton-Sanders Race Picks Up Steam
BYLINE: By MAGGIE HABERMAN and ALAN RAPPEPORT; Amy Chozick and Nick Corasaniti contributed reporting.
SECTION: Section A; Column 0; National Desk; FIRST DRAFT; Pg. 19
LENGTH: 1016 words
Hillary Clinton and Senator Bernie Sanders escalated their battle over health care and gun control on Wednesday as the race for the Democratic presidential nomination intensified.
The back-and-forth began when Mr. Sanders gave Mrs. Clinton fresh material to criticize him with on health care policy, an issue the two have tangled over for days.
Mr. Sanders had vowed to release details of how he would pay for his Medicare-for-all proposal before the Feb. 1 Iowa caucuses. But when his campaign released a chart listing how he would pay for many of his costly proposals, the plan for universal health coverage -- which some estimates suggest could top $15 trillion -- was not on the list.
In addition, Mr. Sanders's campaign manager, Jeff Weaver, told CNN that, in fact, Mr. Sanders might not disclose those numbers before the caucuses -- the sort of backtracking that has rankled Mrs. Clinton's allies, who believe the Vermont senator is often held to a lesser standard than she is.
Mrs. Clinton and her team pounced. On a conference call with reporters, a campaign spokesman, Brian Fallon, said it was ''alarming'' that Mr. Sanders had not yet detailed how he would pay for his health care plan. And her campaign's policy director, Jake Sullivan, asserted that it was ''simply not possible'' to implement Mr. Sanders's proposal without raising taxes on the middle class.
(Mr. Weaver, interviewed on MSNBC late Wednesday, avoided the word tax, but acknowledged there could be an ''income-based premium for families'' in the eventual Sanders Medicare plan.)
Of course, Mrs. Clinton has advocated a single-payer health care system for years, before President Obama's push for the Affordable Care Act. In an interview with ABC News early Wednesday, she stressed that she was not faulting Mr. Sanders for supporting a single-payer plan, just for his lack of specificity. ''Tell the people how much it will cost them,'' she said. ''Every analysis shows it's going to cost middle-class families and working families.''
Mrs. Clinton has also used the issue, as she has with gun control, to try to play up her ties to Mr. Obama, who remains broadly popular among Democratic primary voters, and to cast Mr. Sanders as at odds with the president.
But Mr. Sanders and his allies struck back Wednesday afternoon, suggesting that Mrs. Clinton was hitting him from the right.
Interviewed on MSNBC, Mr. Sanders defended his record on gun safety, boasting that the National Rifle Association had given him a D-minus for his votes on firearms restrictions, and said he lost a congressional election in 1988 after suggesting a ban on assault weapons.
''To say that I'm kind of a supporter of the N.R.A. is really a mean-spirited and unfair and inaccurate statement,'' Mr. Sanders said.
He also accused Mrs. Clinton of hypocrisy regarding his plan for a single-payer health system.
In Iowa this week, Mrs. Clinton warned that Mr. Sanders's plan was problematic because it would give governors oversight of health coverage in their state. This would potentially give control over the market to Republicans, which Mrs. Clinton said was ''risky.''
On Wednesday, Mr. Sanders countered that Mrs. Clinton's assertion was ''factually incorrect'' because his plans to overhaul the health insurance market would be implemented by the federal government in states whose governors opposed it.
''Now she's attacking me because I support universal health care,'' Mr. Sanders said. ''In 2008 she was attacking Obama because Obama was attacking her because she supported universal health care.''
But a tougher response came from Democracy for America, the progressive political action committee based in Burlington, Vt., that supports Mr. Sanders. In a statement, officials with the group, which grew out of Howard Dean's failed 2004 presidential campaign, called Mrs. Clinton's attacks on Mr. Sanders lies that could endanger Democrats.
''The bald-faced lies about Bernie Sanders's strong record against gun violence and the right-wing attacks on his support for single-payer health care coming from the Clinton campaign have no place in a Democratic primary,'' said Charles Chamberlain, executive director of Democracy for America.
He also accused Mrs. Clinton of shifting positions on the issue. ''Democrats deserve better than to see her flip-flop on that core value now that her progressive opponent is surging in the polls.''
Before endorsing Mr. Sanders, Democracy for America, along with other liberal groups like MoveOn.org, had sought to draft Senator Elizabeth Warren, Democrat of Massachusetts, into the presidential race as an alternative to Mrs. Clinton.
What was striking about the attacks on Mr. Sanders over health care was that they were being delivered by Mrs. Clinton and her campaign, rather than by unrelated surrogates.
Her daughter, Chelsea, has also joined in the offensive, asserting in New Hampshire on Tuesday that Mr. Sanders ''wants to dismantle Obamacare, dismantle the CHIP program, dismantle Medicare and dismantle private insurance.'' (Mr. Sanders denies this, saying he ''helped write the Affordable Care Act.'')
''You know, I adore my daughter and I know what she was saying,'' Hillary Clinton told ABC News on Wednesday morning. ''Because if you look at Senator Sanders's proposals going back nine times in the Congress, that's exactly what he's proposed. To take everything we currently know as health care, Medicare, Medicaid, the CHIP Program, private insurance, now of the Affordable Care Act, and roll it together.''
Former President Bill Clinton, campaigning for his wife in New Hampshire, declined to join in the attack on Mr. Sanders, though he allowed that vigorous debate between the two Democrats was a good thing.
''All they're doing now, or should be doing, is talking about the differences in their positions,'' he said Wednesday afternoon at Keene State College. ''That's good, that's healthy for democracy.''
Amy Chozick and Nick Corasaniti contributed reporting.
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/politics/first-draft/2016/01/13/hillary-clinton-and-bernie-sanders-intensify-fight-over-health-guns-and-costs/
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(Well)
July 15, 2013 Monday
Health Insurance Within Reach
BYLINE: RONI CARYN RABIN
SECTION: HEALTH
LENGTH: 1160 words
HIGHLIGHT: The health care mandate takes effect soon, allowing people to compare and buy policies, but many people are unaware of available subsidies and Medicaid coverage.
Ever since Marci Lieber, a part-time social worker in Brooklyn, learned she was pregnant, she and her husband have been scrambling to find health insurance. But insurers consider pregnancy a pre-existing condition, and won't sell anyone a new policy that covers it.
That changes on Jan. 1, 2014, when insurers will no longer be permitted to deny coverage of pre-existing conditions - and all Americans will be required to have health insurance under the Affordable Care Act. Ms. Lieber, 37, hopes to purchase a policy through New York State's new health exchange as early as this October.
Just in time: the baby is due Jan. 25.
"I hadn't paid super close attention to the A.C.A. I didn't realize it would apply to my life," Ms. Lieber said. She learned she could purchase a policy through the new exchange from a counselor at Community Health Advocates, a consumer assistance program that helps New Yorkers find health coverage.
Ms. Lieber isn't alone. Many Americans still don't realize the A.C.A. is coming into effect, including 6 out of 10 low-income workers who especially stand to benefit, according to a study by the Kaiser Family Foundation. Many mistakenly believe the law has been overturned and few have any idea how they are to go about purchasing health insurance from the online exchanges being set up in each state - or that the federal government intends to help many of them pay for it.
But many efforts are being made to simplify the process of buying insurance and to make the exchanges as user-friendly as possible.
For starters, the state exchanges are Web sites designed to make it possible to purchase health insurance if you don't get it from your employer. If they work as promised, the exchanges will let consumers compare different options as easily as they would booking a trip on Travelocity or researching a car on Edmunds.com. You can find a link to your state's exchange at www.healthcare.gov.
All health plans offered on a state exchange must provide comprehensive coverage that includes doctors' visits, lab work, hospital stays, emergency room services, maternity care, prescriptions, mental health services and children's dental and vision care. Presumably, this means fewer consumers will be stung by minimal coverage and unexpected denials - the fine print of health policies that everyone dreads.
But not all the plans will offer the same level of coverage. Shoppers will find four broad categories. Policies with the most generous benefits will be "platinum" plans; they will have the highest monthly premiums but fewer out-of-pocket costs and lower deductibles. The "gold" and "silver" plans will be somewhat less generous, while those in the "bronze" category will have the cheapest premiums but may require high out-of-pocket costs and deductibles.
The idea is that you will be able to make an apples-to-apples comparison of the prices, provider networks and other details to see which policy best fits your needs. Be aware that the plans may have narrow provider networks - your favorite doctor or the hospital down the street may not be a participant. You'll need to check to see if a certain provider is in the network, advised Sabrina Corlette, a research professor at Georgetown University's Center on Health Insurance Reform.
The exchange should be able to tell you exactly what each plan will cost, given individual circumstances. Be prepared for sticker shock. A 40-year-old nonsmoker may be able to buy a plan for about $4,000 annually or less; someone in his or her 50s may pay double. "Health insurance is an incredibly expensive product," Ms. Corlette warned.
What many consumers don't realize is that even if you earn well above the minimum wage, you may get help purchasing the policy you want. People who earn up to four times the federal poverty level - roughly $45,960 a year for a single person and $94,200 for a family of four - can receive subsidies to help pay for the new coverage. Those earning 250 percent of the poverty level are eligible for additional cost-sharing subsidies.
"The vast majority of currently uninsured are going to be eligible" for some form of subsidy, said Elisabeth Benjamin, vice president of health initiatives with the Community Service Society of New York.
To see if you're eligible for subsidies, and what portion of the cost you will be expected to carry, try this calculator: kff.org/interactive/subsidy-calculator/.
Americans who work at minimum wage jobs, earning less than 138 percent of the federal poverty level, which is $15,856 for a household of one and $32,499 for a household of four, will qualify for free government coverage under Medicaid - but only if they live in a state that is expanding its Medicaid program. The Kaiser Family Foundation has a list of what each state is doing on its Web site.
Medicaid is going to be the safety net for more people in the years to come. "It's free, you don't pay anything, it's comprehensive and it turns out to be the easiest thing to apply for," said Karen Pollitz, senior fellow at the Kaiser Family Foundation.
In many states, all of these transactions are to be handled by the online exchange (Medicaid may require a separate process in some states). You fill out an application, providing your Social Security number and information about your income and family. The exchange will tell you if you are eligible for Medicaid or for a subsidy.
If so, it will tell you the amount, as well as what your share will be (the calculation is based on the price of a midrange "silver" plan). You select a plan, and you can decide whether you want the subsidy paid directly to the insurer or not.
The new system will be a radical departure from the byzantine and often bewildering insurance market we have now. Critics say the exchanges will cost the government a fortune, and warn that the plans may provide access only to a limited number of doctors and hospitals.
Supporters acknowledge that there will be glitches initially and that it may take a while to iron out all the details. And health insurance has never been cheap.
"Out-of-pocket costs are still high, even with the financial assistance," said Jennifer Sullivan, of Enroll America, a nonprofit group that aims to get as many Americans coverage as possible. "People need to see it in context and realize the annual savings they are getting. that moves them to say, 'Ah, this is a pretty good deal.' "
Open enrollment on the new exchanges will run from October 1 through March 31. You will not be able to sign up for insurance after March 31 unless your circumstances have changed, and you are suddenly without coverage because of a divorce or job loss.
Help will be available online or via telephone. Given how difficult insurance purchases have always been, many Americans are likely to need it.
What Does Birth Cost? Hard to Tell
Getting Insurance to Pay for Midwives
Life, Interrupted: The Cost of Cancer
When Doctors Stop Taking Insurance
Grappling With Details of Medicare Proposals
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The New York Times
March 26, 2015 Thursday
Late Edition - Final
Divide in Congress Threatens a Residency Program
BYLINE: By DANIEL E. SLOTNIK
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 18
LENGTH: 983 words
Dr. Savita Gopal, a 27-year-old resident physician at the Family Health Center of Harlem, sat in front of a computer last Thursday, peppering Jacob Doble, a 10-year-old from Harlem, with questions for 20 minutes.
As Dr. Gopal typed copious notes, Jacob, accompanied by his mother, Mekisha Hawkins, said he had been to the emergency room repeatedly in February for asthma, migraines and hallucinations.
''Like what?'' Dr. Gopal asked about the visions.
''I saw a giant dragon that looked like it was trying to get me,'' Jacob replied.
Dr. Gopal, who also gave Jacob a physical examination, said she accepted a residency program at the center last year, after studying at Rutgers New Jersey Medical School in Newark, because she wanted to work with patients who did not have access to adequate care. ''I wanted to continue working in that environment, in an underserved community,'' she said.
Dr. Gopal's residency is supposed to last three years, but its future is uncertain. Her training is paid for by a provision of the Affordable Care Act called the Teaching Health Center Graduate Medical Education program, which is up for renewal this year. The program has allocated $230 million nationwide over five years to try to tackle a worsening shortage of primary care physicians and draw eager young doctors to places where they are sorely needed.
But if Congress does not reauthorize the program, it is unclear what will happen to Dr. Gopal, the 31 other residents at the Harlem center and the hundreds of other residents under the program working at similar centers across the nation.
''Losing them would greatly reduce the care we can provide to the people of Harlem,'' said Dr. Neil Calman, the chief executive of the Institute for Family Health, which operates the center in Harlem.
Residents at the center, he noted, handle almost one-third of the 47,000 annual primary care visits there.
A provision to finance the program for the next two fiscal years is included in a health care bill that is expected to go to a vote in the House of Representatives on Thursday. The bill will also need approval from the Senate and President Obama.
Advocates for the program say it enjoys support among individual politicians, including Republicans. But its roots in the Affordable Care Act mean it could expire, the collateral damage of a deeply polarized Congress.
Representative Charles B. Rangel, a New York Democrat, whose district includes the Harlem center, called the residency program, and health centers in general, ''tremendously successful.'' But he also said in a recent telephone interview that he was worried that political concerns might destroy the program.
''We have to determine just what kind of Congress we're going to have here,'' Mr. Rangel said. ''Will they ever stop fighting health care, for their own constituents?''
Representative Chris Gibson, Republican of New York, said in a statement that he appreciated the young doctors the program had attracted to a health center in his district, in Kingston.
''The training supported by this program improves the odds that my constituents have access to primary care providers,'' Mr. Gibson said. ''Too many upstate New Yorkers have to drive 30 minutes or more to see a doctor. By training and keeping doctors in underserved areas, we're working toward a goal of increasing access to quality health care for more of our communities.''
Dr. Calman cautioned that even if the program were refunded, it would not permanently address the issue.
''It's a short-term fix that leaves programs with anxieties about their futures,'' he said.
The teaching program's residencies train primarily in health centers, rather than traditional teaching hospitals. Health centers, which are based in underserved communities, provide outpatient medical services and often have a sliding pay scale for patients who are uninsured or on Medicaid, the government insurance program for the poor.
The idea is that dealing with preventive medicine for ambulatory patients in such settings will connect primary care doctors to the communities and teach them how to best serve their patients.
The Health Resources and Services Administration, which manages the program, has not yet released an official evaluation.
But a recent policy brief from the Milken Institute School of Public Health at George Washington University indicated that the program has had positive results. The report found that by 2014, 60 residency programs were training more than 550 physicians in 27 states and the District of Columbia. Those doctors could soon serve up to nearly a million patients annually.
In addition to at the centers in Harlem and Kingston, program residents in the area are training at two centers in Brooklyn; one in East Meadow, on Long Island; and one in Danbury, Conn.
The report found that three times as many doctors who served their residencies in the health centers stayed in underserved communities and 91 percent remain primary-care doctors.
Despite the report, Tannaz Rasouli, the director of government relations for the American Association of Medical Colleges, warned against funding the program if it detracted from existing options.
''It's a matter of ensuring that we're not investing in one priority at the expense of another,'' she said.
Last Thursday, Dr. Gopal determined that Jacob's hallucinations were a reaction to steroids he received at a hospital to treat his asthma. After consulting with Dr. Venis Wilder, a faculty physician who was training her, Dr. Gopal prescribed higher doses of his asthma medicines to avoid a similar reaction.
Jacob spoke highly about the attention he received at the clinic. ''They really care about you,'' he said.
Dr. Gopal may be worried about her own future, but she said that was not her main concern.
''The patients are the ones who would be losing out in the long run,'' she said.
URL: http://www.nytimes.com/2015/03/26/nyregion/amid-affordable-care-act-fight-a-health-center-program-tries-to-stay-alive.html
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GRAPHIC: PHOTOS: Dr. Savita Gopal recently examined Jacob Doble, 10, who was having hallucinations, at the Family Health Center of Harlem.
Dr. Gopal is a resident in a federal program that is trying to lure eager young doctors to communities that lack adequate care. (PHOTOGRAPHS BY SAM HODGSON FOR THE NEW YORK TIMES)
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The New York Times
November 9, 2010 Tuesday
Late Edition - Final
What Happens to Health Care Now?
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 34
LENGTH: 877 words
To the Editor:
Re ''G.O.P. to Fight Health Law With Purse Strings'' (front page, Nov. 7):
I have been trying to get angry over the new health care law like so many Americans. I am just filling out my employer's annual ''open enrollment'' benefits selections, and the front page lists the changes affecting my health plan in 2011 as a result of the Patient Protection and Affordable Care Act.
It lists that (1) preventive services will no longer require a co-payment, (2) my 19- to 26-year-old children are now covered and (3) there are no longer any lifetime or annual limits on my policy.
Which part am I supposed to be upset about?
Dan Raemer Brookline, Mass., Nov. 7, 2010
To the Editor:
So the first thing the Republicans want to do in Congress is to roll back health care legislation that is drowning our country deeper in debt. Fantastic!
Let's hope they start with President George W. Bush's Part D prescription benefit. That horribly inefficient piece of legislation will cost the United States hundreds of billions of dollars over the next decade and amounted to a huge giveaway to the pharmaceutical industry and lobbyists.
There are plenty of things in President Obama's legislation that I am not too happy with either, including requiring people to buy insurance. That is a form of taxation in my eyes.
There are plenty of money-saving regulations that should be kept, though. I see an opportunity to achieve some real savings in Medicare spending.
Unfortunately, I expect that this opportunity will lead to political jockeying instead of putting the people first.
L. Ryan Smith Austin, Tex., Nov. 7, 2010
The writer is a chiropractor.
To the Editor:
The House Republican leaders' desire to further restrict abortion coverage in health care reform could threaten private health insurance plans and smacks of hypocrisy. Interfering in families' private medical decisions and in insurance companies' business decisions doesn't sound at all like the smaller, less intrusive government those politicians pledged during the campaign.
Nancy Keenan President, Naral Pro-Choice America Washington, Nov. 7, 2010
To the Editor:
In ''Barack Obama, Phone Home'' (column, Nov. 7), Frank Rich writes, ''Truman roared back in part by daring the Republican Congress to enact its reactionary plans.''
Truman also challenged Congress to endorse his Marshall Plan for war-torn Europe. President Obama should similarly dare his detractors by embracing even the title of what they call Obamacare, since this legislation is as brave, necessary and humane as Truman's celebrated accomplishment.
A. R. Gurney Roxbury, Conn., Nov. 8, 2010
To the Editor:
Re ''To Save Money, Save the Health Care Act,'' by Peter Orszag (column, Nov. 4):
On the one hand, the Affordable Care Act does indeed include many innovative ideas for moving beyond fee-for-service medicine and re-engineering health care delivery. That said, reducing costs through huge cuts in payments to hospitals and physicians is not a tactic to be proud of.
For starters, the cuts will never happen -- slashing $500 billion out of Medicare across 10 years (as planned) is politically infeasible. Does anyone question this?
Worse still, the majority of hospitals and physicians currently lose money caring for Medicare and Medicaid patients. How is the provider industry to function financially if tipped over the edge toward bankruptcy?
Envisioned ''efficiencies'' in health care will save tens of billions of dollars; you get to hundreds of billions only with a chainsaw. The key question is this: Is an expensive and complex health care bill desirable if predicated on the impossible -- and certainly undesirable -- scenario of gutting care for senior citizens?
Let's wake up to this budgetary house of cards.
James L. Field Alexandria, Va., Nov. 4, 2010
The writer is a health care writer, consultant and lecturer.
To the Editor:
I would add a fifth pathway to Peter Orszag's sharply defined observations on saving money in health care: greater use of nonphysician medical providers.
The vast majority of physician visits consist of ''minor'' complaints for which, in fact, a physician is not required. These conditions can easily be managed by well-trained and well-qualified nurse practitioners and physician assistants.
Having worked with and trained such individuals, I have come to develop complete trust in their abilities to handle many, if not most, common medical issues.
Permitting licensed and certified nonphysician medical personnel to form medical practices without physician oversight should significantly increase the number of medical providers and decrease medical costs by tempering the present physician monopoly of our health care.
Carl N. Steeg New York, Nov. 4, 2010
The writer is a retired pediatric cardiologist.
To the Editor:
Peter Orszag says the complexities of the health care legislation make it difficult to explain and champion on a bumper sticker.
Well, what about ''To Save Money, Save the Health Care Act'' -- with a Web address that directs interested parties to a concise breakdown of ways this will happen?
This is just too important for the Democrats to continue to tuck their tails between their legs and slink off to the sidelines. I say get the presses rolling!
Mary Ann Larson New Gloucester, Me., Nov. 4, 2010
URL: http://www.nytimes.com
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The New York Times
June 29, 2012 Friday
Late Edition - Final
A Confused Opinion
BYLINE: By RICHARD A. EPSTEIN.
Richard A. Epstein is a professor of law at New York University and a senior fellow at the Hoover Institution.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTOR; Pg. 25
LENGTH: 851 words
THE stunner yesterday was that Chief Justice John G. Roberts Jr., joined by the Supreme Court's four most liberal justices, wrote the majority opinion that upheld the individual mandate in President Obama's signature Affordable Care Act, which requires Americans to obtain health insurance or pay a penalty. In an ironic twist, the chief justice simultaneously accepted the conservative argument that Congress's power to regulate interstate commerce did not include the power to regulate economic inactivity, like a decision not to purchase health care. The court ruled 5 to 4 on that point, with the chief justice joined by the court's four other conservative justices.
But what Chief Justice Roberts took from Congress with one hand, he gave it with the other: a broad reading of the taxing power. In the majority opinion, he wrote that since paying a penalty for not obtaining insurance could be seen as a tax, and since ''the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.'' He will no doubt attract praise in some quarters for splitting this baby.
But his decision is wrong. As a matter of constitutional text, legal history and logic, the power to regulate commerce and the power to tax should not be separated. It is not good for the court or the country that the chief justice's position in such an important case is confused at its core.
Consider first the constitutional text. Chief Justice Roberts refers to Congress's power to ''lay and collect Taxes.'' But it's worth recalling the surrounding language, which notes that Congress has the power to ''lay and collect Taxes'' only in order ''to pay the Debts and provide for the common Defence and general Welfare of the United States.''
Historically speaking, this clause corrected one of the great weaknesses of the Articles of Confederation (the precursor to the Constitution), which had forced Congress to essentially beg the states for the revenues needed to run its business. By giving Congress independent powers over taxation and other revenue sources, the Constitution ended that dependency. But as a quid pro quo, the Constitution also restricted the use of these revenues to classical public goods -- benefits that must be given to all citizens, if given to any -- like paying off national debts and paying for the nation's defense. General welfare, mentioned in parallel with these two phrases, is best read as covering only matters that advance the welfare of the United States as a whole. The redistribution of income, or ''transfer payments'' among citizens, like those mandated under the Affordable Care Act, doesn't qualify for taxation in this originalist reading of the Constitution.
Through the early 20th century, the Supreme Court was cognizant of this tight relationship between the power to regulate an activity directly and to the power to tax it. The basic idea relies on a simple economic insight: taxation and regulation are close substitutes, so a limitation on one power matters little if the other power is still available. There is no practical difference between ordering an action, and taxing or fining people who don't do that same thing. If the Constitution limits direct federal powers, it must also limit Congress's indirect power of taxation.
In his opinion, Chief Justice Roberts didn't come to grips with the two critical early Supreme Court cases that set out the relationship between the powers of regulation and taxation -- a relationship that survived the New Deal revolution in understanding the Commerce Clause. In the Child Labor Tax case of 1922, the Supreme Court refused to uphold a tax equal to 10 percent of the net profits of any firm that shipped goods into interstate commerce if the firm used child labor anywhere in its plants. Chief Justice William Howard Taft noted that the court's earlier decision in Hammer v. Dagenhart (1918) forbade Congress to use its commerce power to prohibit outright the shipment of ordinary goods across state lines because they were made in factories that used child labor. A heavy tax, the court argued, could not be used to mount an end run around this constitutional obstacle to its own power.
The same point was reinforced in 1936 in United States v. Butler, which struck down a tax on agricultural commodities because it sought to achieve the then unconstitutional regulatory aim of reducing the total acreage in agricultural production. After the 1942 case Wickard v. Filburn, when the Commerce Clause was held to permit such regulation, the tax became just as permissible as direct regulation. Wickard expanded the scope of federal power, but it did nothing to upset the constitutional parity between the taxing and commerce powers.
Chief Justice Roberts has ignored this fundamental principle: If direct regulation is beyond the scope of the Commerce Clause (as he held), then taxation as an indirect route to the same regulation should be off limits as well (as he failed to hold). This is a baby that should not be split. His attempt to do so undermines his ruling, the court and the Constitution.
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The New York Times
November 7, 2015 Saturday
Late Edition - Final
New Yorkers Face Difficult Decisions After an Insurer's Sudden Collapse
BYLINE: By NICHOLAS CASEY
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 19
LENGTH: 1028 words
If anyone could manage to obtain treatment under the Affordable Care Act, it should have been Liz Jackson.
With a severe nerve condition that forced her out of a job, Ms. Jackson did not just qualify for a government-subsidized plan, but she also knew her way around the new system, having been trained as a volunteer ''health care navigator'' to help others sign up.
Yet the collapse of her insurer, Health Republic Insurance of New York -- the largest of 12 health care co-ops nationwide set to close this year -- has left her and more than 200,000 others in a panic over medical coverage after their plan ceases on Nov. 30.
Health Republic lived a short and difficult existence, squeezed by premiums that were low by design and cut off by Republicans in Congress from government subsidies promised along with the federal health care law.
Ms. Jackson, 33, is in a situation more grim than most of those losing coverage. She said she was told by state health care officials this week that she no longer qualified for subsidies promised under the federal law. Without them, she does not know if she will be able to afford insurance after her Health Republic policy ends.
''I'm an advocate for the health care law,'' said Ms. Jackson, who lives in Harlem. ''And if I can't navigate this, who can?''
Health Republic and the 11 other co-ops set to close this year make up more than half of the total plans established under the Affordable Care Act. The 23 organizations -- nonprofit start-ups with consumer-led boards -- were set up as alternatives to government-run plans and were intended to create competition with companies like Aetna and Anthem.
The plans took off but soon encountered financial and political difficulties.
Health care has long been considered one of the most challenging markets for new players, dogged by rising treatment costs and dominated by a few big companies. The cooperatives faced pressure to keep premiums low. Congress also made deep cuts to the funds meant to boost struggling co-ops, reducing that budget by 60 percent.
Health Republic has now become a cautionary tale and a warning to other struggling insurers. The company has also become a source of anxiety, from Albany to Long Island, as some New Yorkers try to determine what insurance plan to sign up for next.
Problems arose in September when state regulators said they were closing the co-op and instructed policy holders to seek new insurance plans on the federal exchange. Initially, Health Republic plans were to stay in effect until the end of the year. But last week, the State Department of Financial Services said it had moved the date to Nov. 30.
The state said in a statement last week that a ''review of Health Republic's finances has found that the company's financial condition is substantially worse than the company previously reported in its filings.'' Consumers have until Nov. 15 to select a new plan under the federal health care law to avoid losing coverage in December.
Health Republic said it had operated transparently with regulators and had had an independent financial review in August. The company said in a statement last Wednesday that it was forced to shut down because it received less than 13 percent of the roughly $149 million that the federal government promised it under the health care law.
Sharon Schanzer, a self-employed graphic designer on the Upper West Side in Manhattan, said the experience with Health Republic had her feeling déjà vu.
Ms. Schanzer said she enrolled after having a similar policy with the Freelancers Union, a group that had been offering low-cost plans to independent workers. But in 2014, the Freelancers Union said it would cancel its plans for roughly 25,000 members, because the federal health care law had made it impossible to continue.
Ms. Schanzer said she opted for a $680-per-month plan from Health Republic. She found the plan affordable with her income, but it was more restrictive than the plan with Freelancers Union, which allowed her to see doctors outside the plan's network. However, she said her opinion of Health Republic changed when she received a letter from the insurer saying it was seeking approval to raise her premium to about $850 per month.
The rate increase never came. Not long later, she received a notice that the company would shut down entirely.
''I had no idea it was a speculative thing at the time,'' Ms. Schanzer said, ''that this was a chance I was taking and it wasn't going to last.''
Some officials in the health care industry said that there were early signs that Health Republic was not on good footing. Kathleen Shure, of the Greater New York Hospital Association, a trade group, said she and others were surprised at Health Republic's low-cost plans because of what it had agreed to pay hospitals and doctors.
''When we saw their premiums announced, we all started scratching our heads,'' she said. ''They had low premiums and a huge network. We thought it was marketing.''
Ms. Shure said Health Republic had been known for being slow to make payments. Now that it will close, her organization is preparing hospitals for what could be an even longer collection process. On Monday, the group's president, Kenneth Raske, sent a letter to hospitals asking them to tally what Health Republic owes.
Ms. Shure added: ''We know not everybody is going to be paid 100 percent, we just don't know how bad it's going to be.''
Health Republic's collapse has left Bonnie Rothman Morris, who runs a public relations company in Dobbs Ferry, N.Y., uncertain about how she will receive treatment for acoustic neuroma, a benign tumor that causes hearing loss, and unsteadiness when she moves.
Every year, she goes for an expensive daylong procedure that involves an M.R.I. and visits to two specialists to review the tumor. This year, she said, when she made her appointment, the doctor's assistant told her there was a chance she would have to pay the bills herself if Health Republic failed to pay.
Ms. Morris canceled her visit, which was scheduled for Monday.
''I am going to wait until I have health insurance that I can trust will pay the bills,'' she said.
URL: http://www.nytimes.com/2015/11/07/nyregion/new-yorkers-face-hard-decisions-after-collapse-of-health-republic-insurance.html
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GRAPHIC: PHOTO: Liz Jackson volunteered helping people sign up for a health insurance plan under the Affordable Care Act. Now, she's worried about finding new insurance for herself after the closing of her provider. (PHOTOGRAPH BY NICOLE CRAINE FOR THE NEW YORK TIMES)
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The New York Times
May 15, 2016 Sunday
Late Edition - Final
Sorry, We Don't Take Obamacare
BYLINE: By ELISABETH ROSENTHAL.
Elisabeth Rosenthal (@nytrosenthal) is a New York Times correspondent who is writing a book about the health care system. A continuing conversation about health care costs and pricing in the United States is on the Facebook group page Paying Till It Hurts.
SECTION: Section SR; Column 0; Sunday Review Desk; NEWS ANALYSIS; Pg. 1
LENGTH: 1720 words
AMY MOSES and her circle of self-employed small-business owners were supporters of President Obama and the Affordable Care Act. They bought policies on the newly created New York State exchange. But when they called doctors and hospitals in Manhattan to schedule appointments, they were dismayed to be turned away again and again with a common refrain: ''We don't take Obamacare,'' the umbrella epithet for the hundreds of plans offered through the president's signature health legislation.
''Anyone who is on these plans knows it's a two-tiered system,'' said Ms. Moses, describing the emotional sting of those words to a successful entrepreneur.
''Anytime one of us needs a doctor,'' she continued, ''we send out an alert: 'Does anyone have anyone on an exchange plan that does mammography or colonoscopy? Who takes our insurance?' It's really a problem.''
The goal of the Affordable Care Act, which took effect in 2013, was to provide insurance to tens of millions of uninsured or under-insured Americans, through online state and federal marketplaces offering an array of policies. By many measures, the law has been a success: The number of uninsured Americans has dropped by about half, with 20 million more people gaining coverage. It has also created a host of new policies for self-employed people like Ms. Moses, who previously had insurance but whose old plans were no longer offered.
Yet even as many beneficiaries acknowledge that they might not have insurance today without the law, there remains a strong undercurrent of discontent. Though their insurance cards look the same as everyone else's -- with names like Liberty and Freedom from insurers like Anthem or United Health -- the plans are often very different from those provided to most Americans by their employers. Many say they feel as if they have become second-class patients.
This disappointment is fueling renewed interest in a ''public option'' that would supplement current offerings. That idea found support from both Senator Bernie Sanders and Hillary Clinton as the Affordable Care Act was making its way through Congress. It was taken up again last week by Mrs. Clinton, when she suggested allowing people 55 and over to buy into Medicare, the government-run insurance for people 65 and over, which is accepted by virtually all hospitals.
Some early studies of the impact of the Affordable Care Act plans are proving patients' grumbling justified: Compared with the insurance that companies offer their employees, plans provide less coverage away from patients' home states, require higher patient outlays for medicines and include a more limited number of doctors and hospitals, referred to as a narrow network policy. And while employers tend to offer their workers at least one plan that allows them coverage to visit doctors not in their network, patients buying insurance through A.C.A. exchanges in some states do not have that option, even if they're willing to pay higher premiums.
Many of the problems may well be the growing pains of a young, evolving system, which established only broad standards for A.C.A. plans and allowed insurers -- a large majority of them for-profit -- considerable leeway in designing their exact offerings. The specific requirements and policing mechanisms vary by state, and are still works in progress.
Daniel Polsky, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, is among the researchers who have been studying the law's effects on patients' access to care. ''We hear lots of complaints, but we really don't know the extent of the problem because there's still very little data,'' he said.
The legislation created four tiers of insurance -- bronze, silver, gold and platinum. The different levels represent the amount of medical costs a patient could expect their insurance to contribute: 60, 70, 80 or 90 percent. But within each tier there are dozens of plan designs that give buyers the choice of different premiums, deductibles and networks of doctors, among other things. And the options are different in each state. The A.C.A.'s target audience included both low-earning Americans -- those too wealthy to qualify for Medicaid but too poor to afford commercial insurance -- and those who could not buy insurance through an employer, either because they were self-employed or because their jobs for small companies didn't offer coverage.
The research thus far suggests that the differences between plans offered through the A.C.A. and those offered by employers may be quite significant. A study in the policy journal Health Affairs found that out-of-pocket prescription costs were twice as high in a typical silver plan -- the most popular choice -- as they were in the average employer offering. In research conducted with the Robert Wood Johnson Foundation, Dr. Polsky found that 41 percent of silver plans offered a ''narrow or very narrow'' selection of doctors, meaning at best 25 percent of physicians in an area were included. The consulting firm Avalere Health found that exchange plans had 42 percent fewer cancer and cardiac specialists, compared with employer-provided coverage.
Some of the problems may have been predictable. When designing the new plans, for-profit insurers naturally tended to exclude high-cost, high-end hospitals with whom they had little clout to negotiate discounts. That means, for example, that as of late last year none of the plans available in New York had Memorial Sloan Kettering Cancer Center in their network -- an absence that would be unacceptable to many New York-based employers buying policies for their employees. Another issue is out-of-state coverage, which many A.C.A. plans don't offer aside from emergencies, and which is routinely offered in policies from companies -- especially large ones -- with workers in more than one state.
As a result, many parents who were excited that they would be able to keep their children on their policies until age 26 have discovered that this promise has gone unfulfilled. When Sara Hamilton of New York was shopping on the exchange for a plan to cover her and her two young-adult children -- who live in distant states -- she discovered that none of the plans covered doctor visits in those places.
And when Simon F. Haeder of the University of Wisconsin and his colleagues studied the plans sold on the California exchange, they found that they included 34 percent fewer hospitals than those sold on the open market and tended to exclude the priciest medical centers, like Cedars Sinai, a highly regarded hospital that runs the largest heart-transplant program in the country.
Plan size, of course, is not the only consideration. The research also showed that those limitations might not matter so much for patients' health: The distance traveled and the quality of the providers was similar under both types of policies. He acknowledged, however, that California's exchange, called Covered California, has higher standards for plans than others do, and those results may not be typical.
For certain patients, narrower networks can be attractive because they tend to have lower premiums. A recent analysis by the management consulting firm McKinsey & Company found that premiums were 22 percent higher for plans with broad, as opposed to narrow, networks.
Meanwhile, as researchers continue to evaluate the pros and cons of new exchange plans, patients are discovering the pitfalls.
In 2013, Angie Purtell of Tega Cay, S.C., bought a gold plan offered by Coventry Health Care. When notified that the plan would double its monthly premium the following year, to nearly $1,000, she went shopping again on the state exchange and chose a Blue Cross silver plan for $500. It was branded ''Choice.''
But when she tried to visit her longtime doctor using the new plan, she found she could not. The doctor's practice, while in South Carolina, was not covered because it is affiliated with the Carolina Medical Center, a few miles over the border in Charlotte, N.C.
In order to make smart choices, patients need far clearer and more accurate information about the plans' restrictions as well as which doctors and hospitals are in the network. Yet such information is rarely available, and early research suggests that only a fraction of the doctors listed in some directories are available to see new patients.
''Now that you have the A.C.A., we really need to talk about what is an adequate network,'' Mr. Haeder said. ''But we can't really talk about that until we know that the listings are accurate, and they're not.''
ACROSS the country, lawmakers and regulators are refining the plans' requirements to make sure they work better. And regulators are trying to mandate better information, provided in a more consumer-friendly format.
As of this year, the government requires all the plans listed on the national online exchange -- used by 38 states -- to provide accurate, up-to-date directories. But such directories are often hundreds of pages long, and there is little enforcement. Even the government advises consumers to double-check with their insurers.
The Centers for Medicare and Medicaid Services recently proposed that states develop quantitative requirements for adequate networks -- how many specialists of a certain type, for example, are necessary in a specific geographic area. But after protests from insurers and some states, the agency settled -- for now -- on a more limited fix that allows states and insurers more time to address the problem.
Next year, the government will begin requiring insurers to label plans ''standard'' (an average number of doctors for an exchange plan) versus ''broad'' or ''basic'' for those offering more or less choice. A few states are enacting their own laws.
But health and consumer advocates say progress is too slow, often leaving patients in the dark as they struggle to buy and use the new plans. Even as conservatives in Congress and the presumptive Republican presidential nominee, Donald J. Trump, have vowed to repeal the A.C.A., many consumers just want the system to work better.
''I'm putting my energy into improving transparency and information,'' Dr. Polsky said. ''Otherwise, we're headed to a poorly implemented strategy that just ticks people off.''
URL: http://www.nytimes.com/2016/05/15/sunday-review/sorry-we-dont-take-obamacare.html
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The New York Times
February 5, 2016 Friday
Late Edition - Final
Health Care Signups Exceed Hopes, With 4 Million Newcomers to Federal Marketplace
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 824 words
WASHINGTON -- About 12.7 million people signed up for health insurance under the Affordable Care Act or had their coverage automatically renewed in the third annual open enrollment season, the Obama administration said Thursday.
Sylvia Mathews Burwell, the secretary of the Department of Health and Human Services, said the signups exceeded her goals and her expectations. ''Open enrollment for 2016 is over, and we are happy to report it was a success,'' she said.
Most of the plan selections were for people in the 38 states -- more than 9.6 million -- who used the federal website, HealthCare.gov. The other 3.1 million people were enrolled in states that run their own marketplaces.
Ms. Burwell said she was pleased to see that four million of the people signing up through HealthCare.gov were new to the federal insurance marketplace in 2016. This, she said, shows that ''marketplace coverage is a product people want and need.''
The administration predicted in October that 11 million to 14 million people would choose health plans for 2016 by the end of open enrollment. The total reported on Thursday is slightly above the midpoint of that range.
Ms. Burwell said that 28 percent of consumers who signed up through HealthCare.gov were in the 18-to-34 age bracket, about the same proportion as last year. Insurers had been hoping to see an increase because those consumers tend to be relatively healthy, so money from their premiums is available to help insurers pay for the care of people who are less healthy.
The three-month open enrollment period began Nov. 1 and ended on Sunday. People who selected health plans must pay their share of the first month's premium to activate their coverage. Enrollment tends to decline during the year as some people fail to pay premiums, some qualify for Medicaid or employer-sponsored insurance, and some drop their marketplace coverage for other reasons.
In March 2015, the Obama administration announced that nearly 11.7 million people had selected health plans or had been automatically re-enrolled through the public marketplaces. In September, the administration said, actual enrollment stood at 9.3 million -- about 20 percent lower.
Federal officials said there might be a smaller decline this year because the new numbers included some cancellations and were therefore more accurate. Still, officials said, they did not know how many of the people with marketplace coverage this year were previously uninsured.
The administration said that more than 17 million uninsured people had gained coverage under the health law because of the new public marketplaces, the expansion of Medicaid and the opportunity for young adults to stay on their parents' insurance plans until age 26.
Administration officials carefully track the enrollment numbers, which they regard as a yardstick for the success of the Affordable Care Act.
It is unclear how the enrollment data might affect election-year politics. Republican presidential candidates want to uproot the health care law. In the latest poll by the Kaiser Family Foundation, people reporting unfavorable views of the law outnumbered those with favorable views, 44 percent to 41 percent.
In vetoing a bill to repeal major parts of the health law last month, President Obama cited changes that have occurred in the last five years.
''The nation's uninsured rate now stands at its lowest level ever, and demand for marketplace coverage during December 2015 was at an all-time high,'' Mr. Obama said. ''Health care costs are lower than expected when the law was passed, and health care quality is higher, with improvements in patient safety saving an estimated 87,000 lives.''
About seven in 10 consumers who had 2015 coverage through HealthCare.gov returned to the federal marketplace and actively selected plans for 2016, federal officials said. More than half of them switched plans.
Four million people used new search tools on HealthCare.gov to find out if particular doctors or prescription drugs were covered -- a ''sign of the seriousness and time they put into their decisions,'' Ms. Burwell said.
Among states using HealthCare.gov, the federal government reported the largest number of signups in Florida (1.7 million), Texas (1.3 million), North Carolina (613,500) and Georgia (587,850).
California, which has its own marketplace, reported signups of nearly 1.6 million, including 425,000 new customers.
In the last week of open enrollment, nearly 700,000 people signed up or were automatically re-enrolled in coverage through the federal marketplace.
Kevin J. Counihan, the chief executive of the federal marketplace, said he saw a surge in the final week in Miami, Atlanta and Chicago and in Texas cities including Dallas, Fort Worth, Houston, Corpus Christi, Harlingen and Laredo.
Follow the New York Times's politics and Washington coverage on Facebook and Twitter, and sign up for the First Draft politics newsletter.
URL: http://www.nytimes.com/2016/02/05/us/politics/latest-obamacare-sign-ups-exceed-expectations.html
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(First Draft)
October 14, 2014 Tuesday
Today in Politics
BYLINE: THE NEW YORK TIMES
SECTION: US; politics
LENGTH: 1247 words
HIGHLIGHT: Democrats struggling to hang on to the Senate, who have been drowning in dreary news, have spotted a hopeful sign: Democratic voters who sat out the 2010 elections are becoming more interested in voting this time.
In Early Voting Numbers, a Glimmer of Hope for Democrats
Good Tuesday morning from Washington, where President Obama will discuss his strategy to combat the Islamic State with about 20 foreign defense chiefs, Mayor Bill de Blasio of New York is in town to talk national security, and the chances of the Republicans taking control of the Senate have inched up to 68 percent.
Democrats struggling to hang on to the Senate, who have been drowning in dreary news, have spotted a hopeful sign: Democratic voters who sat out the 2010 elections are becoming more interested in voting this time.
In North Carolina, which permits early voting, 42,230 people had requested ballots as of Monday. Of that group, 17,364 did not vote in 2010, and among them, Democrats outnumber Republicans, 39 percent to 32 percent.
While it is difficult to predict how many of the North Carolina voters will ultimately turn in their ballots, the trend in Iowa suggests reasons for Democratic optimism.
The Democratic Senatorial Campaign Committee reports that more than 21,000 Iowans who did not vote four years ago have already cast ballots: 53 percent of them are registered Democrats, 28 percent are unaffiliated, and 19 percent are Republicans.
These so-called drop-off voters have been a major focus of the Democratic turnout operation, as the party tries to overcome the lethargy typical of midterm elections and attract a younger, more diverse electorate, similar to the one that re-elected President Obama in 2012.
Michael P. McDonald, a University of Florida professor who tracks voting trends, said early indications suggested that the Democratic effort was paying off, though he cautioned against over-reading the data.
Republicans dismissed the numbers and said that they were gaining ground in early voting as they intensified their own outreach.
- Carl Hulse
A Kentucky Senate Debate With Little Warmth and Lots of Fuzziness
It was a night of unanswered questions.
Drawing raised eyebrows in recent days for refusing to say whether she voted for President Obama, Alison Lundergan Grimes, the Democrat running for the Senate in Kentucky, didn't budge Monday night.
To divulge the answer, she said, would compromise "the constitutional right for privacy at the ballot box," she said in a debate with Senator Mitch McConnell, whose chief strategy has been to link his rival to the unpopular president.
Mr. McConnell did some fudging of his own on a question that has dogged him: What would become of the state's popular health care exchange, Kynect, which has brought coverage to more residents than in almost any other state, if the Affordable Care Act is repealed?
"The website can continue, but in my view, the best interest of the country would be achieved by pulling out Obamacare root and branch," he said. (Of course, Kynect would almost certainly collapse without the federal subsidies provided under the Affordable Care Act.)
Despite the fuzziness of both replies, the tight race has drawn such a deluge of TV ads that the debate - the only one scheduled - seemed to take on the nasty tone of the campaign.
- Trip Gabriel
Voter ID Debate Raises Secretary of State Races' Profile
Can you name the secretary of state in your state?
Probably not. The races used to be obscure, with many voters unsure of what secretaries of state actually do. (They administer elections.)
The contentious debate over voter ID laws and whether they discriminate against minority voters is changing all that.
On Tuesday, iVote, a national group devoted to aiding Democratic secretary of state candidates, will air its first ad in Nevada, one of four states it is targeting this year. (The others are Colorado, Iowa and Ohio.)
The group says that it has raised $1 million and that it plans "significant" ad buys in Iowa and Nevada.
"What we've seen over the last several years is a systematic effort on the part of Republicans to very blatantly put barriers in the way of people voting," said Jeremy Bird, co-director of iVote.
The Republican State Leadership Committee has its own initiative to support its secretaries of state candidates.
- Trip Gabriel
What We're Watching Today
President Obama meets with Gen. Martin E. Dempsey, the chairman of the Joint Chiefs of Staff, and defense chiefs from 20 countries at Andrews Air Force Base to discuss the Islamic State threat. Representatives from Australia, Bahrain, Belgium, Britain, Canada, Denmark, Egypt, France, Germany, Iraq, Italy, Jordan, Kuwait, Lebanon, Netherlands, New Zealand, Qatar, Saudi Arabia, Spain, Turkey and the United Arab Emirates are attending.
Mayor Bill de Blasio of New York comes to Washington with William J. Bratton, the police commissioner, to meet with F.B.I. and Homeland Security officials. Mr. de Blasio will also meet with the president of the National Education Association.
In Arkansas, Senator Mark Pryor and Represenatative Tom Cotton face off for their second debate in two days at 7 p.m. (CDT) at the University of Arkansas at Fayetteville.
Hillary Rodham Clinton is in San Francisco headlining an event at a Dreamforce software convention and is expected to take questions after her speech.
Wendy Davis Says 'Wheelchair Ad' Is Staying on the Air
Wendy Davis will not pull the infamous "wheelchair ad" aimed at her opponent in the Texas governor's race, Greg Abbott, who has used a wheelchair since a jogging accident in the mid-1980s.
To demonstrate her commitment to the ad, which has been roundly criticized, Ms. Davis held a news conference on Monday with supporters - several in wheelchairs - who spoke up in its defense. An Abbott campaign adviser responded by posting an article on Twitter that referred to those supporters as "props."
That prompted an outraged tweet from Lamar White Jr., one of the Davis supporters at the news conference: "I am a human being. Not a campaign prop. I volunteered to speak because @WendyDavisTexas is right."
The 30-second ad features an empty wheelchair and a voiceover criticizing Mr. Abbott for "collecting millions" in a lawsuit about his own accident (he was struck by a tree while jogging) and then arguing against similar settlements for others.
The ad "is about one thing - hypocrisy," said Zac Petkanas, the Davis campaign's communications director.
Ms. Davis is well behind in the polls: A Texas Lyceum survey released Oct. 1 had her down by nine percentage points to Mr. Abbott. Given those numbers, the ad should test the maxim that there is no bad publicity. The campaign said the ad had tested well in focus groups. And on Facebook and YouTube, it had been viewed more than a half-million times by Monday night.
- Ashley Parker
What We're Reading Elsewhere
Howard Fineman, writing for The Huffington Post,doesn't have such a rosy outlook about the president's record.
Philadelphia magazine asks if Tom Wolf, the Democrat challenging the Republican incumbent, Gov. Tom Corbett, has what it takes to govern Pennsylvania.
The Arkansas Democrat-Gazette provides a rundown of the sparring between Senator Mark Pryor and his Republican challenger, Representative Tom Cotton, in the Senate debate on Monday.
The Wall Street Journal says turnout in the southwestern corner of Wisconsin will determine whether Scott Walker is re-elected governor.
Miscellany: Blue, a Democratic blog in New Hampshire, stumbled on a post by a Republican state senator that called a Democratic congressional candidate as "ugly as sin." Read the full rant.
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July 25, 2012 Wednesday
The Story So Far
BYLINE: LINDA GREENHOUSE
SECTION: OPINION
LENGTH: 1485 words
HIGHLIGHT: In the wake of the decision to uphold the Affordable Care Act, I can't remember a time when there was such fixation on a single justice's single vote.
History may someday settle on one of the competing and contradictory narratives now running rampant within the virtual Beltway to explain the decision by Chief Justice John G. Roberts Jr. to save the Affordable Care Act. Since that day seems far off, here in quick summary are the emerging story lines.
In "a singular act of courage," Chief Justice Roberts took a bullet for the country, Jeffrey Toobin suggests in a New Yorker article that describes the chief justice's entering the courtroom on the morning of June 28 with eyes "red-rimmed and downcast." (Was he suffering from the seasonal allergies that plague everyone else in Washington?) Chief Justice Roberts thus exemplifies the "virtue of compromise in an era of Occupiers, Tea Partiers and litmus-testing special interests," according to David Von Drehle's admiring Time magazine cover story.
On the other hand, the chief justice is a cynical manipulator who "wanted to maintain the Supreme Court as a playpen for anti-government sophistry" while avoiding trashing up the court altogether, Timothy Noah claims in The New Republic. Can it be that he is fooling us all because "we've never really gotten over our collective crush on John Roberts," an affection both "silly and undeserved," as Jeff Shesol maintains on Slate?
Worse yet, the chief justice is a traitorous turncoat and a weakling to boot, unable to withstand liberal "bullying," the improvident choice by a feckless president for the Supreme Court's center chair, as James Taranto asserts in The Wall Street Journal under the headline "We Blame George W. Bush."
I can't remember a time when ScotusWorld (my name for the community of those who hang on the Supreme Court's every word, "Scotus" being a widely used acronym for "Supreme Court of the United States") was so fixated on a single justice's single vote. Chief Justice William H. Rehnquist disappointed his conservative allies from time to time, provoking howls of outrage from Justice Antonin Scalia, for example, when he agreed with Justice Ruth Bader Ginsburg in 1996 that the Virginia Military Institute's exclusion of women was unconstitutional and again in 2000 when he wrote an opinion for the court reaffirming the Miranda ruling ].
These were major constitutional disputes of their day, with Chief Justice Rehnquist's votes coming as near total surprises, and yet the denizens of ScotusWorld basically shrugged and moved on. Perhaps the right saw the old chief as so reliable that he could be forgiven a liberal vote every decade or so, while the left, for its part, knew better than to regard these occasional aberrations as the harbingers of a new Rehnquist. And of course, at the end of the day, these big-deal cases were just cases. They lacked the dramatic potential of a confrontation between a president and a chief justice, two Harvard Law School-trained avatars of a generation, defined at least until now by their differencesrather than by their common gifts of intellect and ambition. With that delicious plot spoiled, there's understandable hunger to know what happened.
At least, hunger within ScotusWorld (which includes readers of this column). Polls conducted in the aftermath of the health care decision have received attention for revealing the public's fickleness toward the court. A Gallup Poll from mid-July shows that while last September, half of all Republicans approved of "the way the Supreme Court is handling its job," only 29 percent approve today. Last September, 46 percent of Democrats approved of the court (little different from the Republican approval rate), while now 68 percent do. Only among self-described independents was there no significant change: 44 percent approved of the court last September, and 42 percent approve today.
On reflection, these figures are not as startling as they seem. Nathaniel Persily, a law professor at Columbia with expertise in polling and public opinion, shared with me an unpublished article in which he makes the point that few people know much about the Supreme Court and very few ever read a Supreme Court opinion. Rather, they take their cues about the court from opinion leaders they trust.
So it's not far-fetched to assume that in our polarized and supersaturated media environment, Republicans exposed themselves for the past two years to a drumbeat of criticism of the Affordable Care Act and to the fervent desire on the part of people they respect for the Supreme Court to strike it down. For Democrats, of course, the opposite occurred: Rachel Maddow instead of Rush Limbaugh. Perhaps independents listened to both, or neither. Or possibly these folks had not invested their own identity with a particular view of the matter. Their view of the law, in other words, was a matter of judgment rather than self-definition. Or maybe the independents simply tuned out altogether, not caring enough about the decision to let it change their minds one way or another about the worthiness of the Supreme Court.
What I found most surprising - truly startling - about the recent Gallup poll was what it showed about public attitudes toward Chief Justice Roberts. Again, the poll showed wide swings among Republican and Democratic views of the chief justice: from 67 percent favorable among Republicans a year ago all the way down to 27 percent today, and among Democrats, from 35 percent favorable up to 54 percent. (Independents showed a smaller swing, in the negative direction, from 47 percent favorable down to 38 percent.)
Nothing too surprising there, but what jumps out from the poll result is the large number of people in all categories who, barely two weeks after the decision, either "never heard of" Chief Justice Roberts or had no opinion of his performance: 31 percent of all adults; 30 percent of Republicans; 27 percent of Democrats; and 34 percent of independents.
Can this be possible? Is there really such a disconnect between those of us living in ScotusWorld and the great majority outside, who have myriad other concerns and who don't really care whether the chief justice changed his vote at the last minute, or whether he vacations on an "impregnable island fortress" or the Jersey Shore?
Totally typical, Professor Persily assures me, reminding me of aPew Research Center poll two years ago, when the Supreme Court was prominently in the news because of the retirement of Justice John Paul Stevens and the Senate confirmation hearing for Elena Kagan. Asked to choose the current chief justice from among four names, most said they didn't know and barely a quarter of the respondents chose John Roberts. The others split their guesses among Justice Stevens, in the news for having retired; Thurgood Marshall, dead at that point for more than 17 years; and Harry Reid, the Senate majority leader. Two years later, the much ballyhooed Supreme Court case of the century has been decided, and nothing much has changed in terms of public understanding of the court.
It seems to me that this situation presents Chief Justice Roberts with both a challenge and an opportunity. We know that overall public support for the Supreme Courthas dropped sharply- along with support for all government institutions - in the last few years. Political scientists tell us that "Americans who have a better understanding of how the court operates within the political system and those who pay attention to its decisions are much more likely than others to hold the court in high esteem," as Gregory A. Caldeira and Kevin T. McGuire put it in their chapter of "The Judicial Branch," a volume of essays published in 2005.
Suppose that instead of spending his summer holed up on the island of Malta (see "impregnable island fortress," above) and at his vacation home off the coast of Maine, Chief Justice Roberts undertook some outreach to explain the court to the public. Justice Scalia is taking to the airwaves this summer to promote his co-written book about techniques of legal decision making, and Justice Stephen G. Breyer has been crisscrossing the country for the last few years talking about his own view of the court's role. Justice Stevens is clearly reveling in his unrestrained retirement, giving punchy and quotable speeches and even writing on legal subjects for The New York Review of Books.
John Roberts has great television presence: who could forget his masterful confirmation hearing in 2005? And he surely has something to say now - not, obviously, about the health care ruling or any particular case, but about the court he has known intimately since his days as a law clerk. Producers and news directors would clear their calendars for him. What do people need to know about the Supreme Court? Why should they care? Everyone in ScotusWorld is busy telling the chief justice's story. Let him share the court's story with the rest of us.
When Enough Is Enough
The Mystery of John Roberts
Money or Your Life
The Fire Next Term
Goodbye to Gitmo
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November 16, 2013 Saturday
Late Edition - Final
House Approves Bill That Allows Policy Renewals
BYLINE: By ASHLEY PARKER and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1159 words
WASHINGTON -- Defying a veto threat from President Obama, the House approved legislation on Friday that would allow insurance companies to renew individual health insurance policies and sell similar ones to new customers next year even if the coverage does not provide all the benefits and consumer protections required by the new health care law.
The vote was 261 to 157, with 39 Democrats bucking their party leadership and the White House to vote in favor of the bill. Hours after the vote, Mr. Obama and top aides met for over an hour with insurance executives after industry leaders complained Thursday that they had been blindsided by a White House reversal on canceled policies. The president described the meeting as a ''brainstorming'' session about how to ensure changes to the health care law go smoothly.
The insurance representatives, from more than a dozen companies, said they would work with the administration to protect the financial viability of the new marketplaces, but did not say how. Afterward, Karen Ignagni, the president of America's Health Insurance Plans, a trade group, said it was a ''very productive'' meeting, but would not go into detail.
The legislation approved by the House would go further than the fix announced on Thursday by Mr. Obama, who said he would temporarily waive some requirements of the law and allow insurers to renew ''current policies for current enrollees'' for a year.
Many of the Democrats who supported the bill are facing tough re-election fights back home, and expressed deep frustration with how the administration had handled the early carrying out of Mr. Obama's signature health care law. Representative Nick J. Rahall II, Democrat of West Virginia, who voted for the legislation, said that the White House deserved an ''F-minus'' for its botched rollout of the Affordable Care Act.
''I'm disgusted about it,'' Mr. Rahall said. ''I think heads should roll downtown. Whoever was responsible or may have known that this was going to occur should no longer be employed.''
Representative Ron Barber, Democrat of Arizona, who also joined Republicans in voting for the bill, was equally scathing, calling the rollout ''a disaster.''
''My constituents are pretty upset,'' he said, ''and so am I.''
Representative Fred Upton, Republican of Michigan and the chief sponsor of the House bill, said it would fulfill a promise that Mr. Obama had made to the American people and then broken.
''In the last three years,'' Mr. Upton said, ''the president personally promised that if people liked their current health care plan, they could keep it 'no matter what.' But cancellation notices are now arriving in millions of mailboxes across the country. It's cancellation today, sticker shock tomorrow.''
Mr. Upton, the chairman of the Energy and Commerce Committee, belittled Mr. Obama's proposal, saying it was offered at the last minute, ''as the administration's allies in Congress panicked.''
Senior Democrats criticized the Upton legislation as a ploy that could unravel the entire health care law.
''Don't pretend you care about the American people's health care here,'' said Representative Mike Doyle, Democrat of Pennsylvania. ''You just want to repeal the Affordable Care Act. Democrats are not going to let you do that.''
And Robert Zirkelbach, a spokesman for America's Health Insurance Plans, said insurers, in discussing the bill, had had ''significant concerns on how it would work operationally.''
The outlook for the legislation is unclear in the Senate, where Democrats running for re-election in 2014 are looking for a way to help consumers facing the loss of insurance policies that do not meet requirements of the 2010 law.
Senator Mary L. Landrieu, Democrat of Louisiana, was one of the first Democrats to break with the White House and offer her own proposal, which would allow people to keep their current plans indefinitely.
However, after the president's turnabout on Thursday, many Senate Democrats said they were waiting to see if additional legislation was necessary, and quick action in the Senate is not expected.
House Democrats on Friday used a procedural maneuver to offer a plan of their own called ''Landrieu lite.'' It was similar to the president's proposal in its approach, and it gave Democrats some political cover in that it showed them taking action on the issue.
The Democratic proposal, which was rejected by Republicans, would have allowed people who like their current plans to retain them for a year. Under the Democratic proposal, unlike with Mr. Upton's bill, insurers would not be allowed to sell plans that previously faced cancellation to new customers.
Representative Eric Cantor of Virginia, the No. 2 House Republican, said insurers should be allowed to sell new policies like those now in force because it was extremely difficult for consumers to obtain coverage through the federal website, HealthCare.gov.
But Representative Jim McGovern, Democrat of Massachusetts, said Mr. Upton's bill was an attempt to ''drag us back to the bad old days of the American health care system.''
It would, he said, allow insurers to sell ''cut-rate shoddy policies that lack the consumer protections of the Affordable Care Act.''
The House vote came as Mr. Obama struggles to extricate himself from a political crisis of his own making. Opinion polls indicate that he is losing the trust of many Americans because of his handling of the health law rollout and the debut of the insurance website, which has been paralyzed by technological failures.
Representative Marsha Blackburn, Republican of Tennessee, said the Upton bill would provide relief to some people hurt by the president's health care overhaul.
''The American people have grown weary of this administration spending money that it does not have on programs the American people do not want,'' she said. ''The president's health care law is a great example.''
The White House said Mr. Obama would veto the House bill if it got to him. The bill, the administration said, would reverse progress made in extending coverage to the uninsured.
The House bill says that if an insurer was providing coverage in the individual market on Jan. 1 of this year, it ''may continue'' to offer such coverage for sale next year in the market outside the new insurance exchanges.
People who choose to buy or renew these policies in 2014 would be deemed to be in compliance with the requirement to have insurance, so they would not be subject to tax penalties for violating the individual mandate.
Insurance executives say that the premiums in the new federal and state marketplaces were based on the assumption that younger and generally healthy people who had been enrolled in cheaper plans would move into the new marketplaces. Their presence would help keep prices lower for everyone.
If those healthier people stick with their current plans, insurers say, then the new marketplaces could be filled with older, sicker people, and premiums could rise.
URL: http://www.nytimes.com/2013/11/16/us/politics/obama-to-meet-with-insurance-executives.html
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GRAPHIC: PHOTO: Kathleen Sebelius, left, the health and human services secretary, discussed the health care website on Friday with Shaheda Jenkins, center, and Jaileene Tavarez at a health center in Detroit. (PHOTOGRAPH BY PAUL SANCYA/ASSOCIATED PRESS) (A12)
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January 13, 2016 Wednesday
Hillary Clinton and Bernie Sanders Intensify Fight over Health, Guns and Costs
BYLINE: MAGGIE HABERMAN AND ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 985 words
HIGHLIGHT: Mr. Sanders hit back on Wednesday as Mrs. Clinton continued to assail his positions on health insurance and gun control.
Hillary Clinton and Senator Bernie Sanders escalated their battle over health care and gun control on Wednesday as the race for the Democratic presidential nomination intensified.
Wednesday's back-and-forth began when Mr. Sanders gave Mrs. Clinton fresh material with which to criticize him over health care policy, on which the two have tangled for days.
Mr. Sanders had vowed to release details of how he would pay for his Medicare-for-all proposal before the Feb. 1 Iowa caucuses. But when his campaign released a chart listing how he would pay for many of his costly policy proposals, the plan for universal health coverage - which some estimates suggest could top $15 trillion - was not on the list.
In addition, the Sanders campaign manager, Jeff Weaver, told CNN that, in fact, Mr. Sanders might not disclose those numbers before the caucuses - the sort of backtracking that has rankled Mrs. Clinton's allies, who believe the Vermont senator is often held to a lesser standard than she is.
Mrs. Clinton and her team pounced. On a conference call with reporters, spokesman, Brian Fallon, said it was "alarming" that Mr. Sanders had not yet detailed how he would pay for his health care plan. And her campaign's policy director, Jake Sullivan, asserted that it was "simply not possible" to implement Mr. Sanders's proposal without raising taxes on the middle class.
(Mr. Weaver, interviewed on MSNBC late Wednesday, avoided the word tax, but acknowledged there could be an "income-based premium for families" in the eventual Sanders Medicare plan.)
Of course, Mrs. Clinton was - for years, before President Obama's push for the Affordable Care Act - an advocate for a single-payer health care system herself. In an interview with ABC News early Wednesday, she stressed that she was not faulting Mr. Sanders for supporting a single-payer plan, just for his lack of specificity. "Tell the people how much it will cost them," she said. "Every analysis shows it's going to cost middle-class families and working families."
Mrs. Clinton has also used the issue, as she has with gun control, to try to play up her ties to Mr. Obama, who remains broadly popular among Democratic primary voters, and to cast Mr. Sanders as at odds with the president.
But Mr. Sanders and his allies struck back Wednesday afternoon, suggesting that Mrs. Clinton was hitting him from the right.
Interviewed on MSNBC, Mr. Sanders defended his record on gun safety, boasting that the National Rifle Association had given him a D-minus for his votes on firearms restrictions, and said he lost a congressional election in 1988 after suggesting a ban on assault weapons.
"To say that I'm kind of a supporter of the N.R.A. is really a mean-spirited and unfair and an inaccurate statement," Mr. Sanders said.
He also accused Mrs. Clinton of hypocrisy regarding his plan for a single-payer health system.
In Iowa this week, Mrs. Clinton warned that Mr. Sanders's plan was problematic because it would give state governors oversight of health coverage. This would potentially give control over the market to Republicans, which Mrs. Clinton said was "risky."
On Wednesday, Mr. Sanders countered that Mrs. Clinton's assertion is "factually incorrect" because his plans to overhaul the health insurance market would be implemented by the federal government in states whose governors opposed it.
"Now she's attacking me because I support universal health care," Mr. Sanders said. "In 2008 she was attacking Obama because Obama was attacking her because she supported universal health care."
But a tougher response came from Democracy for America, the progressive political action committee based in Burlington, Vt., that supports Mr. Sanders. In a statement, officials with the group, which grew out of Howard Dean's failed 2004 presidential campaign, called Mrs. Clinton's attacks on Mr. Sanders lies that could endanger Democrats.
"The bald-faced lies about Bernie Sanders's strong record against gun violence and the right-wing attacks on his support for single-payer health care coming from the Clinton campaign have no place in a Democratic primary," said Charles Chamberlain, executive director of Democracy for America.
He also accused Mrs. Clinton of shifting positions on the issue. "Democrats deserve better than to see her flip-flop on that core value now that her progressive opponent is surging in the polls."
Before endorsing Mr. Sanderes, Democracy for America, along with other liberal groups like MoveOn.org, had sought to draft Senator Elizabeth Warren into the presidential race as an alternative to Mrs. Clinton.
What was striking about the attacks on Mr. Sanders over health care was that they were being delivered by the candidate and her campaign, rather than by unrelated surrogates.
Her daughter, Chelsea Clinton, also has joined in the offensive, asserting in New Hampshire on Tuesday that Mr. Sanders "wants to dismantle Obamacare, dismantle the CHIP program, dismantle Medicare and dismantle private insurance." (Mr. Sanders denies this, saying he "helped write the Affordable Care Act.")
"You know, I adore my daughter and I know what she was saying," Hillary Clinton told ABC News Wednesday morning. "Because if you look at Senator Sanders's proposals going back nine times in the Congress, that's exactly what he's proposed. To take everything we currently know as health care, Medicare, Medicaid, the CHIP Program, private insurance, now of the Affordable Care Act, and roll it together."
Former President Bill Clinton, campaigning for his wife in New Hampshire, declined to join in the attack on Mr. Sanders, though he allowed that vigorous debate between the two Democrats was a good thing.
"All they're doing now, or should be doing, is talking about the differences in their positions," he said Wednesday afternoon at Keene University. "That's good, that's healthy for democracy."
Amy Chozick and Nick Corasaniti contributed reporting.
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June 4, 2012 Monday
People With Individual Health Plans Would Save Out-of-Pocket Under Reform, Study Finds
BYLINE: ANN CARRNS
SECTION: YOUR-MONEY
LENGTH: 467 words
HIGHLIGHT: Older and lower-income Americans who buy their own health insurance would save under health reform, a study finds.
6:18 p.m.
People who buy individual health insurance would likely save hundreds of dollars a year in out-of-pocket medical costs under the Affordable Care Act, a study from the journal Health Affairs estimates.
Roughly 11 million Americans under 65 who don't have insurance through an employer are covered by private individual plans. The study found that if the Act had been implemented from 2001 to 2008, the average adult with individual insurance would have saved at least $280 a year on out-of-pocket costs for medical care and prescription drugs.
The savings were greater for those aged 44 to 64 ($589 a year) and for those with low incomes ($535).
Under the act, these individuals likely would buy insurance through newly created "exchanges," with benefits varying by income.
The study didn't examine the impact of expanded benefits under the law on health insurance premiums - the monthly amount paid for coverage -- which might be expected to rise as benefits are expanded, offsetting any out of pocket savings. But the study cited two reports (one from the Congressional Budget Office in 2009, and another from RAND in 2010) suggesting that better management of competition under the exchanges, along with an increase in healthier people buying insurance, could reduce premiums.
Whether the health reform law is fully implemented is now up in the air due to a United States Supreme Court challenge. The court is expected to issue a ruling in the case in late June.
Steven Hill, a senior economist at the Center for Financing, Access and Cost Trends, part of the Agency for Healthcare Research and Quality in Rockville, Md., authored the study. (A summary is available free online.)
To do the analysis, Mr. Hill used a nationally representative sample of adults from data gathered by the agency. He compared 2,672 adults with individual insurance from 2001 to 2008, and compared them to thousands of adults who had insurance through small and large insurers. (Results were adjusted for inflation.)
The study found that adults with individual insurance spent an average of $1,100 each year on out-of-pocket medical costs and prescription drugs, compared with $607 for those getting insurance through small employers and $546 for those with coverage through large employers.
Another impact of the reform law, the study found, was a reduction for all adults with individual insurance in the likelihood of having to spend more than $6,000 on out-of-pocket costs.
Do you have individual insurance? How much do you pay out of pocket for medical care?
Help in Deciding if Medical Tests Are Needed
Many Americans Struggling to Pay Medical Bills
Cost of Long-Term Care Insurance Keeps Rising
Rising Health Costs Are a Top Financial Concern of the Affluent
Will High-Deductible Health Insurance Plans Become the Norm?
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April 25, 2014 Friday
Late Edition - Final
Oregon Panel Recommends Switch to Federal Health Exchange
BYLINE: By ROBERT PEAR and KIRK JOHNSON; Robert Pear reported from Washington, and Kirk Johnson from Seattle.
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 776 words
WASHINGTON -- With encouragement from the Obama administration, an Oregon panel recommended Thursday that the state scrap the website for its beleaguered health insurance exchange and use the federal marketplace instead.
State officials concluded that it would be much less expensive to use the federal site, HealthCare.gov, than to repair the one built specially for the state, Cover Oregon. The first option would cost $4 million to $6 million, while the second would cost $78 million, state officials said.
The Oregon exchange -- like those in Hawaii, Maryland and Massachusetts -- has been plagued with technical problems that have made it difficult for consumers to enroll online. All four states have Democratic governors who strongly support President Obama's effort to expand coverage under the 2010 health care law.
The exchange is a keystone of the health care law: a website where consumers can compare private health plans, enroll and obtain subsidies to help defray the cost. Three dozen states are already using the federal exchange.
Greg Van Pelt, an adviser to Gov. John Kitzhaber of Oregon, told Congress this month that ''the launch of the Affordable Care Act in Oregon has been bumpy,'' and that ''the website is only partially functioning.''
Aaron Albright, a spokesman for the federal Centers for Medicare and Medicaid Services, which runs HealthCare.gov, said Thursday, ''We are working with Oregon to ensure that all Oregonians have access to quality, affordable health coverage in 2015.''
The board of the Oregon exchange plans to meet Friday and is expected to approve the recommendation by its technology options work group.
Governor Kitzhaber said he agreed with the panel's advice.
''I think their recommendation to use the federal website technology is the right call,'' he said. ''It is the most reliable and least costly way to ensure that we have a working website for the next enrollment period.''
For most states, the initial six-month enrollment period ended on March 31. But the Obama administration allowed Oregon to extend the application period through April after Mr. Kitzhaber said that technology problems had ''created delays, confusion, and frustration'' for people trying to use the state exchange. The next open enrollment season is scheduled to start on Nov. 15 and continue for three months.
Oregon has received $305 million in federal grants to build its exchange, according to the Congressional Research Service.
Representative Greg Walden, Republican of Oregon, said: ''Cover Oregon is the worst financial failure in information technology in state history, and it was completely avoidable. Today's admission of failure underscores the need to stop the waste and get the truth. How did this happen? Who was in charge?''
Representative Darrell Issa, Republican of California and chairman of the House Committee on Oversight and Government Reform, was equally critical. ''Federal officials should insist that Oregon foot the bill for the state's transition to the federal exchange,'' he said. ''Federal taxpayers should not be stuck with the bill twice for this disastrous project.''
Kathleen Sebelius, the secretary of health and human services, approved the Oregon exchange on Dec. 7, 2012, saying she was confident that it would be ready to provide coverage to consumers in 2014. But in February, the federal government delivered a devastating critique of the Oregon exchange, saying it had ''no integrated project schedule'' and no ''overarching dedicated project manager'' to keep work on track. Moreover, it said, the state did far too little to supervise its main information technology contractor, Oracle.
For Mr. Kitzhaber, a former emergency room doctor who has staked his political career on health care issues, and for Democrats in the Oregon Legislature who backed his enthusiastic embrace of the Affordable Care Act, the political fallout is far from over. He is running this fall for a fourth term and has said he expects the exchange's failure to be the issue of the campaign. But he has a fund-raising advantage over Republican rivals, and it will be an uphill battle for Republicans to unseat him in a Democratic-leaning state that has not elected a Republican governor since 1982.
In any case, health policy debates in Oregon, which once seemed a matter of shared consensus, have become deeply politicized, and the issue is likely to reverberate in state politics between now and Election Day.
Oregon is not the only state to shift course. Maryland decided three weeks ago to abandon its dysfunctional website and use software developed for the Connecticut exchange, one of the most successful in the country.
URL: http://www.nytimes.com/2014/04/25/us/politics/oregon-considers-handing-troubled-insurance-exchange-to-us.html
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October 19, 2013 Saturday
Late Edition - Final
Out of Network, Not by Choice, and Facing Huge Health Bills
BYLINE: By TARA SIEGEL BERNARD
SECTION: Section B; Column 0; Business/Financial Desk; YOUR MONEY; Pg. 1
LENGTH: 1383 words
Once the cardiologist figured out why Raquel and Michael D'Andrea's 9-week-old daughter was so frail and unable to eat, he immediately sent her to the hospital for heart surgery.
''He told us to go home, get packed and get to the hospital, where they will be waiting for us,'' Ms. D'Andrea said. ''That was very shocking, but we did it.''
There was little time to think about the intricacies of their insurance plan, but Ms. D'Andrea knew she had already selected a comprehensive plan a few years earlier. She gave her insurance card to the hospital staff, but her daughter, Sienna, was ultimately treated by several doctors who were not in their plan's network.
''We assumed that because we showed them our insurance card and nobody had any objections, we were covered,'' said Ms. D'Andrea, 35, of Farmingdale, N.Y. ''But I also wasn't in the mind-set to ask, or to have them stop doing heart surgery on her.''
Sienna left the hospital in early March, two weeks after a successful operation repaired her aorta. But she had a rough road ahead. She went home with a feeding tube in her nose.
And just a few weeks later, after vomiting through the night, she spent another 17 days in the hospital. As the family finally arrived back home in mid-April, piles of bills from out-of-network doctors started to roll in.
It's not uncommon for patients who visit an in-network hospital to learn later that they've been treated by out-of-network providers, resulting in thousands of dollars in charges. And while the Affordable Care Act generally caps what consumers must spend out of pocket when using providers within their plan's network, it doesn't protect consumers from large bills from outside providers. Those providers may be free to charge the consumer for the balance of the bill that the insurer did not pay, known as ''balance billing.''
''When the doctors work in the hospital, not for the hospital, which is often the case, they're not obliged to join the same networks as the hospital,'' said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. ''And patients generally have no say in selecting those doctors. Sometimes the patients don't even see them -- for instance, if their X-rays get sent to a radiologist or their tissue to a pathologist,'' patients won't even know the name of that doctor until the bill comes.''
This generally happens because the hospitals don't always assign doctors to the patient. Individuals may begin treatment with a doctor who accepts their insurance. But if that doctor refers the patient to another specialist, or works with an anesthesiologist who isn't in the network, the patient is likely to end up with a bill from that provider, said Gerard F. Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins University Bloomberg School of Public Health. ''About the only thing you can do is to go to a hospital where the M.D.'s are all hospital employees,'' he added.
Some states limit the amount that out-of-network hospitals and doctors can charge above what insurance has covered, experts said, but there are no federal curbs on balance billing. The new health care law, does, however, offer some protections for people who need emergency care: insurers cannot charge more for co-payments and co-insurance for emergency services than they would charge when you use in-network providers. Insurers must also pay out-of-network emergency providers according to a standard schedule, in hopes of lessening the likelihood that patients will be left with enormous bills.
Still, there's nothing in the law that stops health care providers from billing consumers for the balance, which is what often happens -- and exactly what the D'Andrea family experienced. ''This is not an issue that the Affordable Care Act fixes,'' said Timothy S. Jost, a professor at the Washington and Lee University School of Law and expert on health care laws. ''It is conceivable that the problem gets worse for some people if the Affordable Care Act encourages narrower networks, which some people think it might do.''
If consumers use providers within their network, their annual out-of-pocket costs will vary depending on the type of plan they choose (bronze, silver or gold, for example) and their household income. But the new law states that those expenses cannot exceed $6,350 for individuals and $12,700 for a family of two or more in 2014. (This is true for all plans bought on the exchange, and for many individual plans.)
So what sort of recourse do consumers have when they receive big bills from out-of-network providers? The first step is to make sure your insurance plan paid what it should have, since many plans provide some coverage for out-of-network services. And if you were treated for an emergency service (in an emergency room or an extension of it), make sure the insurer paid at least what they would have paid to an in-network provider, said Cheryl Fish-Parcham, deputy director of health policy at Families USA, a Washington consumer advocacy group. Consumers should also check to see if their state has any additional protections against balance billing. Finally, consumers should talk to their providers about reducing any remaining charges.
Consumers would do well to follow the lead of Ms. D'Andrea's mother, Livia Cooper. The couple relied on her to deconstruct and analyze the reams of invoices that arrived in their mailbox -- including a collection notice -- since they were busy caring for Sienna.
Ms. Cooper spent countless hours poring over the bills, trying to make sense of it all. ''It was so overwhelming,'' said Ms. Cooper, who had to close the women's boutique she ran with Ms. D'Andrea so they could focus on Sienna, who is now 9 months old. ''We received department bills and there could be 60 invoices on one printout. You would have a bill for $8,100 from one department or $6,500 from another department. It was hard to figure out what was covered, what wasn't covered and what was balance-billed.''
The billing service for the doctors initially wanted the D'Andreas to enroll in its budget plan, which Ms. Cooper refused to do before figuring what the couple actually owed. Her persistence ultimately paid off. She finally reached a supervisor in the billing department and explained that ''we had insurance, were paying the co-insurance, co-payments and deductibles, and could not afford to pay any more than what we were obligated,'' she said. She also pointed out that the providers were paid what they would have been paid if they were in the network.
As a result, many of their bills were reduced, and some were forgiven. The surgeon who repaired Sienna's heart was in the plan's network, for instance, but the assisting surgeon was not. And even though the insurer paid the assisting surgeon the same amount as the main surgeon, Ms. Cooper said that the couple was billed for $4,100, or the balance not covered by insurance. The billing department asked the couple to file an appeal with the insurer, which they did. As a result, the insurance company paid an additional $700 and the surgeon wrote off the balance.
Ms. D'Andrea and her husband, who operates a small entertainment and D.J. business and also refurbishes homes, ultimately paid about $10,000 in out-of-pocket expenses, Ms. Cooper estimates.
Since the couple's current health plan will terminate at the end of the year, they are now trying to choose a plan on the New York exchange that includes Sienna's doctors -- another tedious process. ''Sienna's situation is such that it makes us very nervous,'' said Ms. Cooper, who is helping the couple research various plans. ''You don't know who the doctors are on different plans because there are no lists.''
As my colleague Abby Goodnough reported earlier this week, many of the state-run exchanges do not have provider directories or search tools on their Web sites -- at least not yet -- so customers cannot easily check which doctors and hospitals are included in a particular plan's network.
And even though the D'Andreas could not have known that out-of-network doctors were treating their daughter, it underscores how important it is to ensure all of their providers will be on the plan they ultimately choose. ''Basically, if you're out of network,'' Ms. Cooper said, ''you're out of luck.''
URL: http://www.nytimes.com/2013/10/19/your-money/out-of-network-not-by-choice-and-facing-huge-health-bills.html
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Sienna D'Andrea, 9 months old, with her mother, Raquel, and grandmother Livia, who spent weeks deciphering and renegotiating Sienna's medical bills. (PHOTOGRAPHS BY DONNA ALBERICO FOR THE NEW YORK TIMES) (B6)
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March 19, 2012 Monday
Late Edition - Final
Debate on Health Care Returns With Intensity
BYLINE: By MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; THE CAUCUS; Pg. 11
LENGTH: 621 words
For months, Mitt Romney has tried to deflect attention from his rivals' accusations that his health care plan was the inspiration for President Obama's overhaul. That task will be harder in the coming days.
This week is the two-year anniversary of Mr. Obama's health care law, and Republicans in Washington are planning to celebrate with a series of attacks. Next week, the Supreme Court will hear three days of arguments about whether the law is constitutional. The hoopla will be enormous.
The string of events will serve to push health care to the front of the public and political agenda - a development that is bound to embolden Mr. Romney's Republican rivals as they seek to undermine his march toward the presidential nomination.
Here is a guide to the health care hullabaloo in Washington: The Background
Mr. Obama signed the Affordable Care Act - Republicans call it ''Obamacare'' - on March 23, 2010. It quickly became Example No. 1 for Republicans who argue that Mr. Obama is a big-government president who dreams of European-style socialism.
The Republican National Committee is promising to spend this week making that case ''across multimedia platforms'' and with ''surrogates to drive the message on the national, state and local levels.''
That will mean new opportunities for Rick Santorum and other Republicans to argue that Mr. Romney's health care plan was similar to what Mr. Obama put in place. On Friday, Kenneth T. Cuccinelli II, the Virginia attorney general, who has been waging a legal battle against the Affordable Care Act, said Republicans would be ''effectively giving up the issue'' of health care if they nominated Mr. Romney.
The Supreme Court
Next Monday, the Supreme Court will begin three days of oral arguments about whether the law's requirement that individuals buy insurance is unconstitutional. Both sides are gearing up for a political carnival outside the court building in Washington, as well as an extended debate that will play out on the cable news networks for the entire week.
Mr. Romney has repeatedly sought to draw clear distinctions between the plan he helped develop in Massachusetts and the kind of system he would support at the federal level. He has repeatedly said he would work to repeal the health care law if elected president.
But the fact is that Mr. Romney's state plan includes a measure requiring residents to buy insurance - a mandate - that is similar to the controversial provision at the heart of the challenge to Mr. Obama's law. That similarity will be fodder for cable news chatter as the networks seek to fill hours of analysis during the court's deliberations.
The Politics
In the meantime, Mr. Santorum and Newt Gingrich will be looking for ways to blunt Mr. Romney's momentum during this week's primaries in Illinois and Louisiana. Already, the Red White and Blue Fund, a ''super PAC'' backing Mr. Santorum, is running an ad in Illinois that attacks Mr. Romney on the health care issue.
''His health care takeover?'' a narrator says in the ad. ''The blueprint for Obamacare.''
Mr. Santorum has been particularly critical of Mr. Romney on the issue, echoing Mr. Cuccinelli in saying that Mr. Romney would not be able to make the case against Mr. Obama's overhaul. In San Juan, P.R., over the weekend, Mr. Santorum said that ''it's the equivalent of malpractice to nominate someone who gives away the most important issue in this race.''
In an interview on Fox News last week, Mr. Romney said that ''time and again, I've pointed out I'm not in favor of a health care plan that includes a national mandate.'' He will most likely have to repeat that line time and again in the coming days.
This is a more complete version of the story than the one that appeared in print.
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Angry Democrats Study the Tea Party's Playbook;
Political Memo
BYLINE: JONATHAN MARTIN
SECTION: US; politics
LENGTH: 1176 words
HIGHLIGHT: Democrats have begun gathering to try to harness worries about President Trump and recreate their version of the conservative mass movement that sprang up in 2009.
AVENTURA, Fla. - Freshly energized protesters are taking to the streets, members of Congress are being confronted in their districts by constituents angry over health care, and wealthy donors are turning fear into action.
Eight years after Republicans united after a stinging electoral defeat to oppose President Barack Obama, Democrats are channeling an even deeper anxiety over President Trump - and a far shallower defeat - into a newfound burst of organizing.
Party leaders, eyeing the hugeprotests last weekend and growing worries over the promised repeal of the Affordable Care Act, are hoping to recreate the mass movement that sprang up in 2009 and swept Republicans to power in the House and in governor's races across the country - a Tea Party equivalent from the left.
And they are turning to the same playbook that guided their conservative counterparts in the aftermath of Mr. Obama's election: creating or expanding a number of groups outside the formal architecture of the party, focusing on often-overlooked state legislative and redistricting campaigns, and bringing together frightened fund-raisers to underwrite it all.
Recreating the conditions for a second lightning strike will be difficult. The kind of soaring unemployment that followed the worst recession since the Depression is not likely anytime soon, and with many House districts gerrymandered by Republicans and few Republican-held Senate seats open in 2018, the political terrain is more forbidding for Democrats now. Only two Republican Senate seats - in Nevada and Arizona - are plausibly available to Democrats at the moment, while Democrats must defend 10 seats in states won by Mr. Trump. The most hard-fought campaigns may be the 38 governor's races that will take place over the next two years.
But in the fury at Mr. Trump and, specifically, the brewing anger over the Republican attempt to repeal the Affordable Care Act, Democrats see passions on their side and the same potential for overreach that animated conservative voters in 2009 and 2010.
"You can see this health care thing just unraveling right in front of them," said James Carville, the longtime Democratic strategist, invoking the political maxim that "the mover on health care loses."
"To do something is to lose."
The left begins with a head start: Mr. Trump is already far more unpopular than Mr. Obama was at the outset of his presidency.
The looming question is whether Democrats can sustain the passion of their contributors and activists once the shock of Mr. Trump's inauguration wears off. The success of the post-Obama Democratic Party will be determined by whether the progressives who are roused right now will open their checkbooks and show up at their local Democratic committees in the lead-up to the 2018 midterm elections.
Democrats must "rebuild from the grass roots up and go back to being competitive in state and local elections," said Eric T. Schneiderman, New York's attorney general and a Democrat. "Even if Hillary Clinton had won, the Republicans still would be controlling 69 of 99 state legislative chambers and 33 governor's mansions."
The depth of the party's problems was a recurring theme as donors, still in disbelief over Mr. Trump's election, gathered over inauguration weekend at a palm-tree-shaded golf resort here to plot their comeback and tune out the transfer of power 1,000 miles to the north.
David Brock, the combative Democratic organizer, brought together about 150 contributors and operatives for a three-day conference that underscored the opportunity that liberals have and the challenges they face in trying to create their answer to the Tea Party.
That the hard-charging Mr. Brock - polarizing even among Democrats and identified chiefly with Mrs. Clinton - could summon a broad array of progressives was an indication of the energy coursing through the left.
Strolling by the pool and talking about how to rebuild, in between presentations with titles like "What the Hell Just Happened?," the donors expressed a determination to fight back.
"There's a real urgent energy," said Susie Tompkins Buell, one of Mrs. Clinton's top fund-raisers. "This is bigger than women's rights, this is bigger than human rights, this is bigger than the environment. This is the future of the entire world."
Mr. Brock said he would ask for $40 million this year for his constellation of research and advocacy groups, increasing the individual budget of each.
A host of other progressive groups are broadening their ambitions, as well, including the Center for American Progress, a research group, and Priorities USA, which served as the primary "super PAC" for Democratic presidential candidates in the last two elections. Some liberals who are part of the Democracy Alliance, a progressive umbrella group, are irritated that Mr. Brock staged the event, fearing that he is creating a competitor to their conferences.
Such jostling for organizational supremacy was also a feature of the conservative landscape when the right formed its resistance to Mr. Obama.
But Democrats are already contending with challenges that Republicans never fully confronted after 2008. There was something close to unanimity on the right in its opposition to Mr. Obama's agenda. The Affordable Care Act did not win one vote from a congressional Republican. But Democrats are at odds over whether they should oppose Mr. Trump across the board or selectively work with him where they have common interests.
Putting his marker down in that debate, Mr. Brock told donors that the "coming divide" in the party would be "between those who resist and oppose and those who accommodate and appease."
A debate over Mr. Trump's first 100 days broke out at a session here, with Mayor Rahm Emanuel of Chicago pressing for accommodation at times and Ron Klain, a veteran Democratic operative, urging total opposition.
"My attitude is, there will be things that in the interest of the country we're going to work on, and things we're not because it's not in the best interest," Mr. Emanuel said.
The debate pointed to a more fundamental difference between the political right and left, which could make Democratic unity more difficult: While conservatives are glad to reap the political benefits from halting or undermining an expansion of government, liberals are invested in a well-functioning state.
"You're going to have a harder time getting Democrats to say, 'We don't want government to work,'" said Mr. Schneiderman, who was a panelist at the event.
Follow The New York Times's politics and Washington coverage on Facebook and Twitter, and sign up for the First Draft politics newsletter.
PHOTOS: Simone Bailey and her daughter, Poppy Burrows, traveled to Washington from Chicago for the Women's March on Saturday. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES); A Tea Party protest against the Affordable Care Act at the Capitol in 2009. Democrats hope to stir their own mass movement. (PHOTOGRAPH BY LUKE SHARRETT/THE NEW YORK TIMES)
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Inaugural Speech Dims G.O.P. Hopes for a More Conservative Trump Agenda
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September 29, 2015 Tuesday
The Disturbing Prospect of Trey Gowdy as Majority Leader
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 414 words
HIGHLIGHT: Mr. Gowdy runs the investigation into the Benghazi attack, and built his reputation sponsoring marginal and often bizarre legislation.
The choice House Republicans make to replace John Boehner as speaker will say a lot about how the party is going to handle its current identity crisis. Will it finally take governing seriously, or will it go on using its majority in Congress to shut down the government, hold show votes on health care reform, stymie President Obama and try to stop Hillary Clinton from becoming president?
The current conventional wisdom holds that the leading candidate is the majority leader, Kevin McCarthy of California. Mr. McCarthy, at least, said on Monday that it is time to stop "governing by crisis," and that he would look for "the most conservative solution I can find." That might, possibly, hint that he is open to compromise.
His promotion, however, would leave the majority leader spot open. And, as Jennifer Steinhauer reports today, some in the party are hoping to elevate Trey Gowdy to that position.
Mr. Gowdy, of South Carolina, was elected in 2010 and built a reputation sponsoring marginal and often bizarre bits of legislation, like the 2014 bill that would allow the House of Representatives to sue the president of the United States if it did not like the way the president was enforcing the law.
He's a big supporter of repealing the Affordable Care Act and, of course, of denying federal money to Planned Parenthood.
But Mr. Gowdy has made his biggest splash by running the longest congressional investigation in history, which is ostensibly into the killings at the Benghazi diplomatic compound on September 11, 2012, but most often just seems like an attempt to mess around with Mrs. Clinton's campaign. Mr. Gowdy was part of Representative Darrell Issa's team when he took over the House Government Oversight Committee after the 2010 elections and vowed to conduct "seven hearings a week, times 40 weeks" just to thwart President Obama.
Mr. Gowdy raises lots of money for other members of the committee. And if you're lucky enough to be on their mailing list, you will know that he is the darling of the StopHillaryPAC, which says it is single-mindedly dedicated to doing just that. Mr. Gowdy, for the record, has said he doesn't want to raise money off the Benghazi investigation or to have his name used for that purpose.
Choosing Mr. Gowdy as majority leader would cement the current Republican Party as the party of the marginal right, of obstruction as a substitute for lawmaking, and of the abuse of congressional investigative and subpoena powers for partisan purposes.
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November 28, 2016 Monday
Late Edition - Final
The G.O.P. and Health Care Chaos
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 20
LENGTH: 689 words
What will happen if President-elect Donald Trump and Republicans in Congress carry out their pledge to repeal the Affordable Care Act, the 2010 health reform law? By most estimates, up to 22 million people, many of them poor or older Americans, will lose their health insurance.
Mr. Trump seems to recognize this would be disastrous -- to an extent. Since the election, he has said that he wants to keep the part of the law that prohibits insurance companies from discriminating against people with pre-existing conditions. Without this provision, insurers can deny those customers coverage, charge them exorbitant rates or refuse to cover treatment for those conditions.
But Mr. Trump and other Republicans are delusional if they think that they can preserve that provision while scrapping the rest of the health care law. Insurers are able to offer policies to people with pre-existing conditions because the law greatly expands the number of people who are insured, thus spreading the costs of treating people with chronic conditions over a larger number of paying customers.
The law provides subsidies to help individuals and families buy policies on government-run online health exchanges (those who do not buy insurance are required to pay a tax penalty). Take away or greatly reduce that benefit and millions won't be able to afford the plans, and many insurers will simply stop selling policies or will charge individuals and families much higher rates. The law also expanded Medicaid by financing state programs with federal money. Take away that money, and many states will no longer be able to provide care to millions of poor families.
Republicans have said that Congress could vote early next year to repeal the Affordable Care Act but delay the actual end of the law for a year or two. In theory, that would allow lawmakers to come up with a workable replacement while putting off the consequences of repeal.
But any vote to repeal the law would almost certainly cause insurers -- which know they won't be able to depend on the federal government in the future -- to start pulling their plans from the online marketplaces for 2018 coverage, kicking millions off coverage. State and local governments will have to start planning to increase spending on public hospitals and charity medical care. Consider this: Uncompensated care at hospitals declined by $7.4 billion in 2014 after most major provisions of the law kicked in, according to the Department of Health and Human Services. Those costs would most likely go right back up.
The House speaker, Paul Ryan, and Republican policy experts have sketched out a variety of replacements for the law, but have not coalesced around one plan. All of them would reduce government spending and slash coverage.
One idea backed by Mr. Ryan would create a government-run high-risk pool to help pay for the medical care of people with major health problems who don't have insurance. But previous state and federal high-risk pools did not cover most of the people with pre-existing conditions and suffered large losses, according to the Kaiser Family Foundation. Other Republican ideas include expanding the use of health savings accounts, which would primarily benefit wealthy families that can afford to sock away substantial amounts for future health problems.
Those complexities explain why Senator Lamar Alexander, the Tennessee Republican who leads the Health, Education, Labor and Pensions Committee, recently said it would ''take several years'' to fully replace the Affordable Care Act. Though the law is not perfect, it has greatly increased access to medical care and has made some parts of the health system more efficient by, for example, increasing the use of preventive services.
In discussing the repeal of the law during the campaign, Mr. Trump said, ''There will be a certain number of people who will be on the street dying, and as a Republican, I don't want that to happen.'' He might start by following the maxim to ''first, do no harm.''
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URL: http://www.nytimes.com/2016/11/28/opinion/the-gop-and-health-care-chaos.html
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December 5, 2013 Thursday
Late Edition - Final
Obama Presses Case for Health Law and Wage Increase
BYLINE: By JACKIE CALMES
SECTION: Section A; Column 0; National Desk; Pg. 28
LENGTH: 1127 words
WASHINGTON -- President Obama left the White House on Wednesday for one of the capital's working-class neighborhoods to talk about the economy, not simply to divert attention from the troubles of his Affordable Care Act but also to explain how that law, for all of its flaws, fits into his vision for Americans' economic security and upward mobility.
That vision -- of an economic partnership between government and its citizens -- is one that Mr. Obama has described since he was a state senator in Illinois, and it draws on the legacies of three Republican presidents: Abraham Lincoln, Theodore Roosevelt and Dwight D. Eisenhower.
On Wednesday, he reiterated the policies required to carry it out, even though it has long been clear the opposition from Republicans is likely to make many of them unattainable.
''It's true that government cannot prevent all of the downsides of the technological change and global competition,'' the president said. ''But,'' he added, ''we've also seen how government action time and again can make an enormous difference in increasing opportunity and bolstering ladders into the middle class.''
After weeks on the defensive about problems with the new health insurance marketplaces, Mr. Obama was at times combative toward Republicans. If they oppose his ideas for addressing ''the defining challenge of our time, making sure our economy works for every working American,'' then, he said in remarks directed at Republicans, ''You owe it to the American people to tell us what you are for.''
The address was intended to echo one he delivered two years ago this month in Osawatomie, Kan., where he honored Roosevelt's call a century earlier for a ''new nationalism.'' Drawing historical parallels to past federal investments like land-grant colleges, Depression-era public works, Interstate highways and the G.I. Bill, Mr. Obama on Wednesday pressed for his proposals to promote manufacturing, energy innovations, education, infrastructure projects and more.
Four cabinet members, several Democratic members of Congress, and Mayor Vincent C. Gray of Washington were among the officials on hand, reflecting the importance that the White House had attached to the president's remarks.
He delivered his address from an arts, education and social services complex about six miles from the White House, in the Anacostia neighborhood of Southeast Washington. The site itself symbolized his message: Federal and local governments, corporations, foundations and philanthropists shared its $27 million cost to benefit local residents seeking to escape poverty. He spoke to observe the 10th anniversary of the Center for American Progress, a policy research group that includes former officials from the Obama and Clinton administrations.
Trends since the 1970s, Mr. Obama said, have led to ''a dangerous and growing inequality and lack of upward mobility that has jeopardized middle-class America's basic bargain -- that if you work hard, you have a chance to get ahead.''
He cited statistics putting the gap between the rich and everyone else in the United States on a par with that in Jamaica and Argentina, and showing that children have a greater chance in Canada, Germany or France to move up the social ladder than they do in the United States. The trend, he said, was bad for the economy, social harmony and democracy.
Describing what steps he has taken, Mr. Obama highlighted the health care law.
For decades, he said, health care ''was one yawning gap in the safety net that did more than anything else to expose working families'' to economic insecurity. ''That's why we fought for the Affordable Care Act,'' he said.
Despite the program's problems, he added, the number of insured people is up, medical costs are down and all Americans with insurance have new protections and benefits.
''It is these numbers, not the ones in any poll, that will ultimately determine the fate of this law,'' Mr. Obama said, adding, ''This law is going to work, and for the sake of our economic security, it needs to work.''
Among Republicans seeking the law's repeal, Mr. Obama singled out Senator Mitch McConnell of Kentucky, the minority leader, whose state has one of the most successful new insurance marketplaces: ''He might want to check with the more than 60,000 people in his home state who are already set to finally have health insurance.''
Still, prospects for Mr. Obama's goals in his final three years are hardly promising. His speech came at the close of a year in which none of his other economic initiatives have made it through Congress.
The Senate passed a bipartisan, business-backed immigration bill to give about 11 million illegal immigrants a path to citizenship, but House Republican leaders refuse to take it up. Budget talks with Senate Republicans fizzled, probably dashing Mr. Obama's three-year-old hopes of a ''grand bargain'' on spending and taxes, one that would combine deficit reductions in future years with immediate financing for infrastructure, education and technology projects. Spending cuts are squeezing the very programs that Mr. Obama has wanted to expand.
And the broader problems he addressed in his speech defy easy solutions. Mr. Obama drew some of his biggest applause when he renewed his call for what he sees as a small but crucial step -- an increase in the federal minimum wage, which at $7.25 an hour is lower than the minimum in a growing number of states. He and other supporters say an increase would also help workers earning above minimum wage by creating pressure to increase their pay, and in turn would spur more spending and economic growth.
Especially with low-paying service jobs among the fastest growing in the economy, Mr. Obama said, ''It's well past the time to raise the minimum wage,'' he said.
Mr. Obama's push is timed, in part, to help Senate Democrats pass a measure that would raise the minimum wage to $10.10 in three stages over two years, raise the separate minimum wage for tipped workers and peg both to rise with inflation. But House Republicans oppose the legislation, arguing that an increase would force many employers to cut their work force.
Mr. Obama disputed those arguments, and cited widespread public support for an increase. In a poll last month by CBS News, two-thirds of Americans -- including more than half of Republicans -- said the federal minimum wage should be higher.
The president also called on Congress to extend the food stamps program -- House Republicans' demands for $40 billion more in spending cuts over 10 years has held up passage of a farm bill -- and federal payments for the long-term unemployed.
''Christmas time is no time,'' he said, ''for Congress to tell more than one million of these Americans that they have lost their unemployment insurance.''
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January 13, 2016 Wednesday
Late Edition - Final
Louisiana's New Governor Expands Medicaid, Saying It Will Cover 300,000 More
BYLINE: By RICHARD FAUSSET and ABBY GOODNOUGH; Richard Fausset reported from Baton Rouge, and Abby Goodnough from Washington.
SECTION: Section A; Column 0; National Desk; Pg. 9
LENGTH: 744 words
BATON ROUGE, La. -- On Tuesday, his second day in office, Gov. John Bel Edwards signed an executive order expanding Medicaid coverage under the Affordable Care Act, fulfilling a campaign promise that will expand health coverage to hundreds of thousands of people in one of the nation's poorest states.
The action by Mr. Edwards, a Democrat, under President Obama's health care law was expected to be one of the most significant and immediate results of his election in November, when he defeated Senator David Vitter, a Republican whose campaign was tainted by a prostitution scandal.
Mr. Edwards, the only Democratic governor in the Deep South, in some ways ran as a conservative Democrat, opposing abortion and gun restrictions. But he has also vowed to address the plight of the roughly one in five Louisiana residents who live in poverty, according to federal census figures.
''We are consistently ranked one of the poorest and unhealthiest states, and this cycle will not be broken as long as anyone in Louisiana has to choose between their health and their financial security,'' Mr. Edwards said Tuesday at a signing event at the Louisiana Capitol. He was flanked by health care industry representatives and a handful of the 300,000 working-class Louisiana residents who he said would be newly eligible for Medicaid when the expanded coverage takes effect on July 1.
''This will not only afford them peace of mind,'' Mr. Edwards added, ''but also to help prevent them from slipping further into poverty and give them a fighting chance for a better life. ''
With the change in Louisiana, 31 states and the District of Columbia have now expanded their Medicaid programs under the Affordable Care Act, accepting billions of dollars in federal funds to cover nearly everyone with incomes below 138 percent of the poverty level. That comes to $16,242 for a single person and $33,465 for a family of four.
In Louisiana, 298,000 uninsured adults will be eligible for Medicaid under the expansion, according to an analysis last year by the state's Legislative Fiscal Office. An additional 224,000 adults with private insurance would also be eligible.
Mr. Edwards's predecessor, Bobby Jindal, a Republican, staunchly opposed the expansion of Medicaid. In a July 2013 editorial in The Times-Picayune, the New Orleans newspaper, Mr. Jindal said he was worried that thousands of people in private plans would switch to Medicaid. He also argued that the state, which must eventually contribute 10 percent of the cost of the Medicaid expansion, would ultimately be saddled with rising costs, draining money from other priorities.
''Our federal government is already drowning in entitlement spending; now the feds are trying to drown us as well,'' he wrote. ''States do not need to mindlessly follow this example.''
Mr. Edwards criticized Mr. Jindal's legacy on Tuesday, saying that low-income people had suffered because of ''the previous administration's refusal to expand critical health care services.''
Republicans control both houses of the Legislature, but the decision to expand Medicaid falls within the scope of changes to health care policy that the governor can make unilaterally, said Robert Travis Scott, the president of the Public Affairs Research Council of Louisiana, a private, nonpartisan policy group.
''Now, it is possible that a well-organized legislature could find ways to disrupt it, or block it, or find de facto ways that it can be disrupted,'' Mr. Scott said. ''So far I haven't seen any strong signs that that's going to happen.''
On Monday, Representative Alan Seabaugh of Shreveport, a Republican and one of the most conservative House members, said he was going to start an effort to block Mr. Edwards's Medicaid expansion plan. Mr. Seabaugh gave only scant details of his strategy.
With new legislative sessions about to begin around the country, Republican governors in two other holdout states -- Matt Mead of Wyoming and Dennis Daugaard of South Dakota -- are trying to persuade their legislatures to expand the program.
In Nebraska, Gov. Pete Ricketts, a Republican, remains opposed to expanding Medicaid. But a number of Republican legislators there are pushing a new proposal that would use federal funds to buy private health insurance for about 77,000 low-income people rather than enrolling them in Medicaid. But it is not clear whether the plan can win enough legislative support to override a veto by Mr. Ricketts.
URL: http://www.nytimes.com/2016/01/13/us/louisianas-new-governor-signs-an-order-to-expand-medicaid.html
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March 20, 2015 Friday
Late Edition - Final
Trillion Dollar Fraudsters
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 29
LENGTH: 802 words
By now it's a Republican Party tradition: Every year the party produces a budget that allegedly slashes deficits, but which turns out to contain a trillion-dollar ''magic asterisk'' -- a line that promises huge spending cuts and/or revenue increases, but without explaining where the money is supposed to come from.
But the just-released budgets from the House and Senate majorities break new ground. Each contains not one but two trillion-dollar magic asterisks: one on spending, one on revenue. And that's actually an understatement. If either budget were to become law, it would leave the federal government several trillion dollars deeper in debt than claimed, and that's just in the first decade.
You might be tempted to shrug this off, since these budgets will not, in fact, become law. Or you might say that this is what all politicians do. But it isn't. The modern G.O.P.'s raw fiscal dishonesty is something new in American politics. And that's telling us something important about what has happened to half of our political spectrum.
So, about those budgets: both claim drastic reductions in federal spending. Some of those spending reductions are specified: There would be savage cuts in food stamps, similarly savage cuts in Medicaid over and above reversing the recent expansion, and an end to Obamacare's health insurance subsidies. Rough estimates suggest that either plan would roughly double the number of Americans without health insurance. But both also claim more than a trillion dollars in further cuts to mandatory spending, which would almost surely have to come out of Medicare or Social Security. What form would these further cuts take? We get no hint.
Meanwhile, both budgets call for repeal of the Affordable Care Act, including the taxes that pay for the insurance subsidies. That's $1 trillion of revenue. Yet both claim to have no effect on tax receipts; somehow, the federal government is supposed to make up for the lost Obamacare revenue. How, exactly? We are, again, given no hint.
And there's more: The budgets also claim large reductions in spending on other programs. How would these be achieved? You know the answer.
It's very important to realize that this isn't normal political behavior. The George W. Bush administration was no slouch when it came to deceptive presentation of tax plans, but it was never this blatant. And the Obama administration has been remarkably scrupulous in its fiscal pronouncements.
O.K., I can already hear the snickering, but it's the simple truth. Remember all the ridicule heaped on the spending projections in the Affordable Care Act? Actual spending is coming in well below expectations, and the Congressional Budget Office has marked its forecast for the next decade down by 20 percent. Remember the jeering when President Obama declared that he would cut the deficit in half by the end of his first term? Well, a sluggish economy delayed things, but only by a year. The deficit in calendar 2013 was less than half its 2009 level, and it has continued to fall.
So, no, outrageous fiscal mendacity is neither historically normal nor bipartisan. It's a modern Republican thing. And the question we should ask is why.
One answer you sometimes hear is that what Republicans really believe is that tax cuts for the rich would generate a huge boom and a surge in revenue, but they're afraid that the public won't find such claims credible. So magic asterisks are really stand-ins for their belief in the magic of supply-side economics, a belief that remains intact even though proponents in that doctrine have been wrong about everything for decades.
But I'm partial to a more cynical explanation. Think about what these budgets would do if you ignore the mysterious trillions in unspecified spending cuts and revenue enhancements. What you're left with is huge transfers of income from the poor and the working class, who would see severe benefit cuts, to the rich, who would see big tax cuts. And the simplest way to understand these budgets is surely to suppose that they are intended to do what they would, in fact, actually do: make the rich richer and ordinary families poorer.
But this is, of course, not a policy direction the public would support if it were clearly explained. So the budgets must be sold as courageous efforts to eliminate deficits and pay down debt -- which means that they must include trillions in imaginary, unexplained savings.
Does this mean that all those politicians declaiming about the evils of budget deficits and their determination to end the scourge of debt were never sincere? Yes, it does.
Look, I know that it's hard to keep up the outrage after so many years of fiscal fraudulence. But please try. We're looking at an enormous, destructive con job, and you should be very, very angry.
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January 31, 2016 Sunday
Late Edition - Final
Tax Scams Are Targeting Uninsured, I.R.S. Warns
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 715 words
WASHINGTON -- The Internal Revenue Service is warning consumers about tax scams involving the Affordable Care Act and penalties imposed under the law on people who go without health insurance.
In some cases, the agency said, unscrupulous tax preparers tell clients to pay the penalties directly to them, and they keep the money.
Most people do not owe the payment at all because they have health coverage, such as Medicaid or employer-sponsored insurance, or qualify for one of many available exemptions.
''However,'' the I.R.S. said, ''if you owe a payment, remember that it should be made only with your tax return or in response to a letter from the I.R.S. The payment should never be made directly to an individual or return preparer.''
The creators of these schemes have been ''targeting taxpayers with limited English proficiency and, in particular, those who primarily speak Spanish,'' the tax agency said last week in a bulletin for consumers.
Undocumented immigrants appear to be particularly vulnerable. They are sometimes told that they must make penalty payments directly to a tax preparer because of their immigration status, the agency said.
The health law requires most Americans to have health insurance. For those who flout the requirement, the penalty, also known as a shared responsibility payment, may be $695 or more this year. For many people, the last day to sign up for insurance is Sunday, when the third annual open enrollment season ends.
Unauthorized immigrants are not required to have insurance, though they are often required to pay taxes, and many do so. ''If you are not a U.S. citizen or national, and are not lawfully present in the United States,'' the Internal Revenue Service declared, ''you are exempt from the individual shared responsibility provision and do not need to make a payment.''
The exemption also extends to young illegal immigrants who came to the United States as children and have received a temporary reprieve from deportation under a program created by President Obama in 2012 and known as Deferred Action for Childhood Arrivals.
Ana Cecilia Lopez, a tax lawyer in Bellingham, Wash., said many tax preparers did not ask enough questions to determine their clients' citizenship status -- a crucial factor in deciding if they owe a penalty or are exempt under the Affordable Care Act.
''Some tax preparers are not asking even the most basic questions about a person's legal status,'' Ms. Lopez said. ''They just ask: 'Did you receive insurance? Did your employer give you insurance? No. Did you get health insurance on your own? No. O.K., now you owe this penalty.' ''
Ms. Lopez said she worked with migrant farmworkers who had been in the United States for decades without legal status but had paid income taxes. Tax compliance is considered to be evidence of good moral character and could be helpful if they seek immigration benefits or legal status in the future.
Christine Speidel, a tax lawyer at Vermont Legal Aid, welcomed the government's effort to warn consumers, including undocumented workers in particular. ''This population is very vulnerable to exploitation by tax preparers,'' she said.
The I.R.S. has tried to regulate certain paid tax-return preparers, requiring them to pass certification tests, pay annual fees and take continuing education courses. But in 2014, the United States Court of Appeals for the District of Columbia Circuit struck down the rules, saying the agency had no authority to adopt them.
As a result, the I.R.S. said, some tax professionals who had been suspended or disbarred in disciplinary proceedings have again been allowed to prepare tax returns for consumers.
The national taxpayer advocate at the I.R.S., Nina E. Olson, has found problems with unlicensed tax preparers.
In the absence of national standards, she said, ''a person can hold himself out as a return preparer with almost no knowledge or skill by simply sitting with a taxpayer and working through'' the questions in tax preparation software.
President Obama has proposed giving the I.R.S. more authority to regulate tax preparers. But Republicans, still angry with the agency over what they see as its improper scrutiny of Tea Party groups, have been reluctant to give it additional authority at this time.
URL: http://www.nytimes.com/2016/01/31/us/tax-scams-are-targeting-uninsured-irs-warns.html
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March 21, 2017 Tuesday
Late Edition - Final
Embattled in Washington, President Recharges Among Friendly Crowd in Kentucky
BYLINE: By MARK LANDLER
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 1043 words
LOUISVILLE, Ky. -- President Trump, embattled in Washington, traveled here on Monday to deliver a rollicking populist and nationalist appeal, promising to rewrite trade agreements, clamp down on illegal immigration and keep terrorists out of the country -- all in the service of putting ''America first.''
In a speech ostensibly timed to push the Republican health care law through Congress, Mr. Trump drew deeply on the themes that animated his 2016 campaign, whipping up a rapturous crowd with promises to reopen shuttered coal mines and throw lawless immigrants out of the country.
Mr. Trump promised that health care legislation would undo the ''disaster'' of President Barack Obama's Affordable Care Act. But he presented it less as a cornerstone of his legislative agenda than as a necessary prerequisite to finance deep tax cuts.
''We have to get this done to do the other,'' Mr. Trump declared.
For Mr. Trump, who is enduring one of the most difficult stretches of his young presidency, the rally was a chance to bathe in the adulation of a campaign crowd, a sea of people waving placards that said: ''Buy American. Hire American'' and ''Promises Made. Promises Kept.''
''This place is packed,'' he exulted. ''We're in the heartland of America, and there is no place I would rather be.''
In the packed stands of Freedom Hall in Louisville, the swirl of questions back in Washington -- about the Trump campaign's ties with Russia or the president's debunked assertions that he had been wiretapped by his predecessor -- seemed a million miles away.
That was exactly the point. Mr. Trump's aides have used these campaign-style events to buoy their boss and provide a respite from the pileup of pressures in Washington. Mr. Trump recycled many of his favorite lines from the aftermath of his election victory in November.
''There is no path to 270,'' he said gleefully, recalling the skepticism that he would win an Electoral College majority. He talked about a representative of the ''fake media'' who asked him recently what it would take to unite the Republican Party. ''I said: 'Wait a minute. We won the House. We won the Senate. We won the White House.'''
On the legislative business at hand, repealing the Affordable Care Act, Mr. Trump acknowledged that the Republican bill would have to be changed to make it through Congress. But he offered no details and appeared unconcerned about the ultimate outcome.
''We're going to negotiate; it's going to go back and forth,'' Mr. Trump said. ''In the end, it's going to be great.''
Mr. Trump pointed to Senator Mitch McConnell of Kentucky, who as the Republican leader will have to shepherd health care legislation through the Senate. ''Hey, Mitch, we going be O.K.?'' he said. ''That health care looking good?'' Mr. McConnell introduced Mr. Trump as the leader who would help the United States recover from the wreckage of the Affordable Care Act.
The president saved most of his fire for trade. He said he would renegotiate the North American Free Trade Agreement and other ''terrible'' trade deals to bring jobs and factories back to the United States. The nation, he claimed, has lost 60,000 factories since China joined the World Trade Organization in 2001.
''We sacrificed our own middle class to finance the growth of foreign countries,'' Mr. Trump declared. ''Ladies and gentlemen, those days are over.''
''We won't be played for fools, and we won't be played for suckers anymore,'' the president said.
Mr. Trump noted that he had cleared the way for the Keystone XL and Dakota Access pipelines, and would demand that they be built with American steel. He said that under its new administrator, Scott Pruitt, the Environmental Protection Agency would go from a ''job killer into a job creator.''
Mr. Trump, who last week visited the grave site of President Andrew Jackson in Tennessee, added a new historical figure to his pantheon of populists: Henry Clay, the Kentucky lawmaker who served as speaker of the House and secretary of state in the early 1800s.
Clay, the president said, had pioneered an economic philosophy known as the American System, which he said prefigured his approach: steep tariffs to protect American exports and generous government spending on roads, canals and other public works projects.
''Like Henry Clay, we want to put our own people to work,'' Mr. Trump said. ''We believe in two simple rules: Buy American, and hire American.''
''After spending trillions and trillions of dollars overseas,'' he added, ''we are going to start taking care of our country.''
Mr. Trump left the capital at the end of a tumultuous day that showcased the perils and promise of his presidency.
In the House, lawmakers grilled the director of the F.B.I., James B. Comey, and the director the National Security Agency, Adm. Michael S. Rogers, about ties between the Trump campaign and Russia. In the Senate, Mr. Trump's nominee for the Supreme Court, Neil M. Gorsuch, introduced himself in what will be several days of confirmation hearings before the Judiciary Committee.
Mr. Trump made no reference to Mr. Comey's testimony and only a brief reference to Mr. Gorsuch. He urged the Senate to swiftly confirm ''an outstanding man from an outstanding family.''
This was the third speech of Mr. Trump's presidency that had an explicitly political theme, drawing on his campaign slogan, ''Make America Great Again.'' It had been conceived as a rally with supporters in a state where one of the Republican senators, Rand Paul, had expressed opposition to the Republican health care legislation, which Mr. Trump is backing.
The visit to a major coal-producing state also resonated in the context of Mr. Trump's plans to lift emissions restrictions on coal-fired power plants, something he is expected to do with an executive order on climate issues that the administration has yet to release. Mr. Trump said he had already eliminated some regulations on the coal industry, and he promised that the executive order would do more.
''We are going to put our coal miners back to work,'' he said. ''They have not been treated well. But they are going to be treated well.''
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URL: http://www.nytimes.com/2017/03/20/us/politics/donald-trump-louisville-kentucky.html
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December 2, 2012 Sunday
National
Democrats Expect a Deal On Medicaid Despite Perry
BYLINE: By BECCA AARONSON.
baaronson@texastribune.org
SECTION: Section A; Column 0; National Desk; THE TEXAS TRIBUNE; Pg. 39A
LENGTH: 644 words
Despite Gov. Rick Perry's firm opposition to a central tenet of federal health reform -- expanding the state's Medicaid program for those with low incomes -- Texas Democrats remain optimistic that the 2013 legislative session can yield a deal that brings in billions of additional federal dollars.
It will be a tough sell: no Republican lawmaker has gone on record supporting the Medicaid expansion, which would add an estimated 1.8 million Texans to the joint state-federal health plan by 2022.
But State Senator Rodney Ellis, Democrat of Houston, said fiscal conservatives have an incentive to reach an agreement ''because the alternative is going to cost us much more economically and dig a much deeper hole in our budget.'' Some Democratic lawmakers have already proposed legislation that would help them circumvent Mr. Perry or else produce a bipartisan compromise that might gain the Obama administration's support.
Under the Affordable Care Act, President Obama's health care overhaul, the federal government would cover 100 percent of the costs of expanding state Medicaid programs for three years, a share that would taper to 90 percent in later years. The Kaiser Family Foundation, a nonpartisan research group, estimated the expansion would cost Texas $5.7 billion from 2013 to 2022, which the organization called a modest price compared with the $65.6 billion that would be covered by the federal government.
The United States Supreme Court's ruling this summer allowing states to refuse to expand Medicaid gave Republican governors leverage to negotiate changes to the health care overhaul. And Mr. Perry holds the power to veto any legislation that would expand Medicaid in Texas.
''What the federal government needs to focus on is giving states more flexibility in delivering care,'' said Catherine Frazier, the governor's spokeswoman.
Mr. Ellis has filed a bill to put the option of Medicaid expansion on a statewide ballot as a provisional amendment to the Texas Constitution. Giving the deciding power to voters would relieve political pressure on Republican legislators and alleviate fear of a veto, he said.
Representative Garnet F. Coleman, Democrat of Houston, is also trying to provide a path toward Medicaid expansion. He plans to file an omnibus Medicaid bill that could be altered during the legislative session to incorporate Republicans' conditions for Medicaid expansion. One idea is co-insurance, Mr. Coleman said, which some Republicans have endorsed to get new Medicaid enrollees to pay a portion of their monthly health care premium.
Both political parties agree that Medicaid needs to be changed. In their 2011 budget negotiations, state legislators underfinanced Medicaid by $4.7 billion. And as the program's enrollment and costs grow, fewer providers are accepting Medicaid clients because of the state's low reimbursement rates.
Republicans say expanding Medicaid before it is overhauled will bankrupt the state or force lawmakers to redirect money from other areas of the budget, like education.
''To make the system work, we need permission from the federal government to do things like charge co-pays, promote access to private health insurance and encourage personal responsibility,'' Senator Jane Nelson, Republican of Flower Mound and chairwoman of the Senate Health and Human Services Committee, wrote in an editorial on her official Web site.
In an e-mail, Ms. Nelson said she could not support Medicaid expansion ''as directed by the Affordable Care Act.''
A representative of the federal Department of Health and Human Services said the agency ''is currently evaluating areas where there may be flexibility.''
If the state and the federal government cannot reach a deal to expand Medicaid in Texas, it is unclear whether any federal public assistance would be available to those people who would have qualified under the expansion.
URL: http://www.nytimes.com/2012/12/02/us/texas-democrats-expect-deal-on-medicaid-despite-perry.html
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December 23, 2013 Monday
Small Businesses Showing Little Interest in State SHOP Exchanges
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1391 words
HIGHLIGHT: In part, it’s because businesses that want to offer health insurance to employees can find other ways to do so.
For advocates of the Affordable Care Act, a central reform to help small businesses buy health insurance was the creation of state-run exchanges. As the law's designers intended, a small company could go onto the exchanges and compare the virtues of competing plans. It could then offer its employees a choice from among several policies, even from different carriers - a benefit few companies now use. It could enroll in those plans online, and if the business were small enough, it could get temporary to offset the cost.
"The marketplace is still the most important provision in the Affordable Care Act for small businesses," said John Arensmeyer, chief executive of the liberal-leaning Small Business Majority in November, after the Obama administration announced that it would delay online enrollment in the 32 Small Business Health Options exchanges operated by the federal government until next October (the rest are operated by individual states and Washington, D.C.). Earlier in the year, the administration had restricted businesses to choosing just one exchange plan in 2014.
While the travails of the federally run SHOP exchanges have been widely reported, many of the state-run exchanges - which together could serve about two-fifths of the nation's small businesses - have faced their own problems in attempting to field a small-business health insurance exchange.
Five states have faced delays in implementing important elements of their exchanges. In California, which has by far the largest population of businesses with fewer than 50 employees, small businesses could not enroll in an insurance plan until Nov. 25. Prior to that, businesses could register online, but had to contact an insurance agent to get a rate quote.
Roy Kennedy, a spokesman for Covered California, the state's exchange, said that the state pushed back SHOP's enrollment function in order to concentrate on deploying the insurance exchange for the individual market. "We felt comfortable doing this because SHOP is open year round and business owners could work through an agent to get a quote," Mr. Kennedy said.
Four other states - Idaho, Maryland, Mississippi, and Oregon - have yet to deploy a functioning SHOP exchange at all. A spokesperson for the Maryland Health Benefit Exchange said the small-business exchange will open next April; the other states have yet to announce start-up dates. A spokesperson for the Idaho exchange said the state had hoped to rely on the federal marketplace for the first year, but in its absence, as of last week, businesses can enroll in a SHOP plan through insurance agents and carriers. The state anticipates deploying its own fully functioning portal by next fall.
In Washington State, the SHOP exchange is only available to businesses in two rural counties in the state's southwest corner. This is because not enough insurance carriers were willing to participate in the exchange, at least at first, according to Bethany Frey, a spokesperson for the Washington Health Benefit Exchange. "Many insurance carriers told us this was a resource issue as they needed to prioritize products for the individual market this first year," Ms. Frey said, adding that she expected to have a statewide network in 2015. "Our system was fully prepared to offer coverage statewide. This wasn't a technology issue or delay."
To be sure, businesses in any state that want to offer health insurance to employees - and no company with fewer than 50 full-time equivalent employees is obliged to provide the coverage - can do so. They can either renew their existing policies or buy new policies that comply with the Affordable Care Act's various standards on the private market. And last week, the Obama administration made it easier for businesses in Washington state shut out from a SHOP insurance plan to use the tax credits in 2014. (The administration did not make any provisions for businesses in Maryland, Mississippi and Oregon, but Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, which is administering the federal exchanges, said, "We are examining ways that eligible small businesses in these states can take advantage of the tax credits next year, and those discussions are ongoing.")
Yet even in states where the roll out appears to have gone relatively smoothly, interest in the SHOP exchanges appears to be low. Lev Ginsburg, of the Business Council of New York, a trade association, said that he had not heard of many problems with implementing the state's . But, he said, few businesses seem to be interested in using it, and those that do find the process laborious. "The time that brokers are spending with their clients has grown threefold or fourfold," Mr. Ginsburg said. "And I don't think the end result is any different - they're walking away with the product from the broker not from the SHOP, and they're walking away with the same product that they would have had anyway. They just have dozens and dozens of questions that they didn't have a year ago." New York has declined to release figures for how many businesses have enrolled in insurance through its SHOP exchange, or even registered an account, the first step toward obtaining coverage.
Among states that have released that information, the share of businesses eligible to participate in SHOP that have created accounts is often at about 2 percent or less. In New Mexico, where the figure for account creation is higher, at about 4 percent, only 44 businesses have enrolled for coverage beginning Jan. 1, said Debra Hammer, a spokeswoman for the New Mexico Health Insurance Exchange.
In Colorado, about 3,000 businesses have opened accounts on the SHOP exchange, said exchange spokeswoman Myung Oak Kim, out of somewhere between 111,000 to 120,000 eligible businesses, according to Census data. But Fort Collins Nursery is not among them. Its owner, Jesse Eastman, said he chose to renew the existing coverage for a dozen or so full-time employees rather than test the unknown. "We decided to opt to see where the chips are going to fall, and keep the plan we know," he said.
For now, Mr. Eastman is missing out on the chance to offer his employees a choice of health plans, an efficiency that until now has been largely limited to bigger companies. In recent years, some insurers have quietly begun offering multiple plans to small businesses, but with restrictions, and offering employees choices from more than one insurer remains especially difficult. On a SHOP exchange, however, which is built for comparing policies and centralizing payment and other administrative functions, choice is not only possible, it is required.
"Choice between carriers is a unique value proposition for a SHOP exchange that wants to do that," said Jon Kingsdale, a consultant and the founding director of the Massachusetts Health Connector, the insurance exchange created by that state's overhaul in 2006. But, he said, "it's more complicated for the employer, and it requires a very aggressive, sophisticated sales effort on the part of the SHOP exchange to promote that value. And the exchanges by and large are just having enough trouble getting up and running, so that most of them have not focused on a sophisticated sales effort with SHOP for small employers." (Some states, like the federal government, are limiting choice across insurers to a single tier of cost-sharing set by the employer.)
Mr. Arensmeyer, of the Small Business Majority, said it would take at least a year to get a true sense of how the exchanges are working. But, he added, "we're not surprised that the numbers are low, and we're not expecting a dramatic increase immediately. I think it's a process to get small-business owners, and perhaps even more importantly, brokers and agents, up to speed on all the processes and how to fully use the new system.
"At the end of the day, the success of the small-business exchanges is going to be very heavily dependent on brokers and agents," he said. "We do expect over time that the marketplaces will drive more competition, and will provide more choice."
What I Needed to Understand About Health Insurance
A Small Business Starts to Navigate the Affordable Care Act
Why Labeling Health Plans Gold, Silver or Bronze Doesn't Help
What the New Health Insurance Law Means for My Workers
My Insurance Was Canceled - And That's O.K.
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May 6, 2014 Tuesday
Late Edition - Final
Massachusetts Starts Over on Health Website After Troubles
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 531 words
WASHINGTON -- Massachusetts will stop trying to fix its deeply flawed health insurance website and instead buy new software to help its residents enroll in coverage, officials there said Monday. But the state will also prepare to join the federal insurance marketplace by the next enrollment period, which starts in November, in case the new system is not working in time.
The decision follows months of problems with enrollment through the state website, which Massachusetts set up in 2006 under its landmark health insurance law. The site worked well until it was revamped last year to comply with the Affordable Care Act, President Obama's health care law. The state had put CGI, the company that also helped design the initially problem-plagued federal exchange, in charge of the overhaul.
Massachusetts announced in March that it was dropping CGI, but it is still negotiating the terms of ending its $69 million contract, of which the state has paid $17 million. The state received $174 million from the federal government to overhaul its health insurance website and has spent about $57 million so far, including the amount paid to CGI, according to Glen Shor, the state's secretary of administration and finance.
Sarah Iselin, a health insurance executive whom Gov. Deval Patrick appointed to oversee fixes to the website, said the new ''dual-track'' plan would cost a little more than $100 million through 2015. But she said it was too soon to know whether the state would seek more federal money; that will depend partly on whether the state ends up owing CGI more money.
The new software will come from hCentive, a Virginia company that helped build the online marketplaces in Colorado, Kentucky and New York. It will allow people to go online and apply for insurance, learn whether they are eligible for subsidies and choose plans, Ms. Iselin said.
In case the new system is not ready by fall, the state will also make sure it is in a position to join the federal exchange, healthcare.gov, for a year. Ms. Iselin said the state would decide ''which is the most viable path'' by midsummer.
''I've said all along that no option on the table would be perfect, and the dual track certainly has its benefits and its challenges,'' she said in a statement. ''It does, however, solve for two realities: We need a reliable website to help people during the next open enrollment period, and we need to be in a position to achieve a fully integrated system by 2015.''
The problems have embarrassed proponents of the federal health care overhaul, which is based on the universal health insurance law in Massachusetts.
According to the federal government, only about 31,700 people signed up for private health coverage through the Massachusetts exchange by mid-April, none of them qualifying for subsidies.
The state has also placed almost 200,000 people in Medicaid temporarily, at a cost of at least $24 million so far, until it can enroll them in Medicaid or subsidized private plans later this year. And it has allowed an additional 100,000 people to temporarily stay in old subsidized plans that are not compliant with the Affordable Care Act, at a cost to the state of about $10 million a month.
URL: http://www.nytimes.com/2014/05/06/us/massachusetts-starts-over-on-health-website-after-troubles.html
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May 21, 2013 Tuesday
Late Edition - Final
New Efforts to Undercut Health Reforms
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 24
LENGTH: 533 words
Congressional Republicans are trying to exploit two controversies bedeviling the Obama administration to undermine the health care reform law. They are using an uproar over misguided tactics by Internal Revenue Service employees to target conservative political groups seeking tax-exempt status as an excuse to prohibit the agency from playing a pivotal role in carrying out the Affordable Care Act. And they want to use a controversy over efforts by the secretary of health and human services, Kathleen Sebelius, to encourage private donations to help enroll people in new health care exchanges as a cudgel to disrupt such efforts.
Under the health reform law, the I.R.S. is required to examine tax returns to determine who is eligible for a tax-credit subsidy to buy health insurance and who must pay a fine for failing to buy insurance. A Republican bill in the Senate would prohibit the I.R.S. from enforcing the reform law (a related Republican bill in the House would do the same unless there are certifications made that the I.R.S. will not target groups or individuals for political reasons).
An investigation by the Treasury Department's inspector general blamed midlevel workers, confusing rules and ineffective management, but it found no evidence that the staff had been under political pressure to focus on conservative groups. Still, Republicans have scheduled hearings to try to link the scandal to health care reform. Putting any limits on the I.R.S. role in determining health subsidies for uninsured Americans would be disastrous.
The controversy surrounding Ms. Sebelius involves her efforts to persuade nonprofit groups and business executives to donate money to or otherwise assist Enroll America, a nonprofit group that aims to help people enroll in new health care exchanges, pick suitable policies and apply for tax credits. She was driven to solicit help because Republicans have repeatedly and shamefully denied requests for money needed for this purpose.
A spokesman for the department said Ms. Sebelius has made only two fund-raising calls. She called the Robert Wood Johnson Foundation and H&R Block, neither of which is regulated by her department. She had engaged in ''a dialogue'' with a wide range of business and nonprofit groups, he said, on how they might help the uninsured.
The problem is that Enroll America is led by former members of the Obama White House, and Mr. Obama's presidential campaigns and some of the people solicited by current or former administration officials felt as though they were being pressured into giving. An investigation by the Government Accountability Office into this matter, as Congressional Republicans are seeking, could shed light on who said what to whom. Whatever the outcome of an inquiry, there are many patient groups working to help the uninsured, and donors should not be deterred from supporting those groups.
Of course, many Republicans are not interested in making sure that millions get help. In fact, as Jeremy Peters reported in The Times last week, the House has voted 37 times to repeal the Affordable Care Act or deprive it of funds since January 2011. That is about 15 percent of the time spent on House floor votes.
URL: http://www.nytimes.com/2013/05/21/opinion/new-efforts-to-undercut-health-reforms.html
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The New York Times
August 20, 2016 Saturday
Late Edition - Final
For Some on Health Exchanges, Only One Plan to Choose
BYLINE: By REED ABELSON and MARGOT SANGER-KATZ
SECTION: Section B; Column 0; Business/Financial Desk; PUBLIC HEALTH; Pg. 3
LENGTH: 1137 words
So much for choice. In many parts of the country, Obamacare customers will be down to one insurer when they go to sign up for coverage next year on the public exchanges.
A central tenet of the federal health law was to offer a range of affordable health plans through competition among private insurers. But a wave of insurer failures and the recent decision by several of the largest companies, including Aetna, to exit markets are leaving large portions of the country with functional monopolies for next year.
According to an analysis done for The Upshot by the McKinsey Center for U.S. Health System Reform, 17 percent of Americans eligible for an Affordable Care Act plan may have only one insurer to choose next year. The analysis shows that there are five entire states currently set to have one insurer, although our map also includes two more states because the plans for more carriers are not final. By comparison, only 2 percent of eligible customers last year had only one choice.
A similar analysis by Avalere Health, another consulting firm, also highlighted the increase in areas with only one insurance carrier.
The market is still in some flux. Final contracts between insurers and the federal government won't be signed until late September. That means it is still possible that additional insurers will choose to enter new markets between now and then, and the competitive picture could improve. It is also possible that some carriers will decide to exit. It was just this week that Aetna surprised regulators and others with the news that it was leaving most of the markets where it offered policies on the exchange, leaving it in just four states.
The Obama administration says it is too early to evaluate competition in the Obamacare markets for 2017. Marjorie Connolly, a spokeswoman for the Department of Health and Human Services, said: ''A number of steps remain before the full picture of marketplace competition and prices are known. Regardless, we remain confident that the majority of marketplace consumers will have multiple choices and will be able to select a plan for less than $75 per month when Open Enrollment begins Nov. 1.''
Many places in the country still have robust choice and competition, including many large population centers like Denver, Los Angeles, New York and Miami. But large areas have limited choice, like the five states that now have only one issuer: Alabama, Alaska, Oklahoma, South Carolina and Wyoming. (Our map also shows Kansas and North Carolina with only one, but the picture may change for parts of those states, because additional insurers have said they plan to enter.)
Large sections of other states may also be down to one carrier, including Florida, Utah and Missouri. It also appears that there is one county in Arizona, Pinal County, between Phoenix and Tucson, where no carriers are set to offer health plans in the marketplace.
While the dwindling competition may not be fatal, ''it isn't ideal,'' conceded Larry Levitt, a senior executive at the Kaiser Family Foundation. People shopping for plans in the exchanges will be left with fewer insurer choices but also, probably, fewer choices of doctors and hospitals because the companies that remain will most likely offer sharply narrow networks.
Evidence from the first years of the marketplace suggests that consumers benefit from more plan choices. According to a study from researchers at the Urban Institute, more competitive markets tended to have lower premiums.
''It's important to have competition in the exchange markets, both to have consumer choice and to keep premiums competitive,'' said Caroline Pearson, a senior vice president at Avalere Health.
But it is unclear whether competitive markets are causing lower premiums, or whether the kinds of places attractive to insurance carriers -- those with many healthy customers and a broad range of doctors and hospitals -- may simply be easier places to offer low-cost insurance. A rule in the health law limits how much of their premiums insurers can keep for overhead and profits, which may hinder a monopoly insurer's ability to overcharge, even in the absence of competition.
The exodus has left some states in flux, with regulators and remaining insurers trying to stabilize the market. In North Carolina, the exit of the UnitedHealth Group and Aetna has left BlueCross Blue Shield of North Carolina to serve the exchange.
The plan says it lost $405 million in 2014 and 2015 on the exchanges, and its chief executive, Brad Wilson, is concerned about the market. The insurer has sought sharply higher premiums for next year. ''Consistently losing money on these plans ultimately puts all of our customers and our business at risk,'' he said.
Insurers say the current rush to the exits underscores their contention that changes need to be made to the law. The decline in participation ''echoes our calls for Congress and the administration to move forward with solutions that will improve the stability of the market and provide the affordable coverage options that consumers need,'' said Clare Krusing, a spokeswoman for the America's Health Insurance Plans, a trade group.
The McKinsey analysis is based on detailed information about the number of carriers in regions of the country known as ratings areas. In 17 states, as well as Washington, D.C., analysts had full information about carriers intending to sell insurance next year.
For the rest of the country, the analysts used complete data from 2016, then updated the information whenever an insurer announced publicly that it was leaving an entire state. Our map does not show places where insurers have exited only portions of those states, and so may show more carriers in some areas than there will be. Nor does it take account of carriers' promises to enter portions of states that have not yet published filings for 2017.
The Affordable Care Act has changed a lot about the individual insurance market -- opening it to people even if they had previous illnesses, guaranteeing a standard package of covered services and providing sliding-scale subsidies to help moderate-income Americans buy their own plans.
But when it comes to competition and choice, the markets may look very much the way they did before the enactment of the law, with regions and even whole states dominated by a single insurance company, typically a Blue Cross plan. The Blue Cross plans traditionally played the role of the insurer of last resort, said Timothy Jost, an emeritus law professor at Washington and Lee who has closely followed the progress of the law. ''They will be the last people to leave the marketplace,'' he said.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
URL: http://www.nytimes.com/2016/08/20/upshot/obamacare-options-in-many-parts-of-country-only-one-insurer-will-remain.html
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September 25, 2013 Wednesday
John McCain Versus Ted Cruz
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 344 words
HIGHLIGHT: Mr. McCain reminded Mr. Cruz that, no matter how much he dislikes health care reform, “the people spoke” and “they re-elected the president.”
It's no secret that Senator John McCain doesn't much like Senator Ted Cruz, whom he once called a "wacko bird." His main grievance is that Mr. Cruz isn't interested in the business of governing, which requires compromise. If Mr. Cruz can't get what he wants, he'd rather muck up the Senate than give in.
This character trait was on brilliant display from Tuesday until this morning. For 21 hours and 19 minutes Mr. Cruz attacked the Affordable Care Act and read from Dr. Seuss's "Green Eggs and Ham," among other time-wasting tactics, in a quasi-filibuster. ("Quasi" because he wasn't actually in a position to stop Senate proceedings, as The National Journal explained.)
Democrats weren't keen on the speech. Neither, for that matter, were Republicans. Mr. McCain was among those who felt Mr. Cruz was merely grandstanding, and earlier today he went so far as to suggest that Mr. Cruz's diatribe was fundamentally undemocratic.
I'd remind my colleagues that, in the 2012 election, Obamacare, as it's called - and I'll be more polite, the A.C.A. - was a subject that was a major issue in the campaign. I campaigned all over America for two months, everywhere I could. And in every single campaign rally I said "we had to repeal and replace Obamacare." Well, the people spoke. They spoke, much to my dismay, but they spoke and they re-elected the president of the United States. No that doesn't mean that we give up our efforts to try to replace and repair Obamacare. But it does mean elections have consequences and those elections were clear, in a significant majority, that the majority of the American people supported the President of the US and renewed his stewardship of this country. I don't like it, it's not something that I wanted the outcome to be. But I think all of us should respect the outcome of elections, which reflects the will of the people.
Ted Cruz Plays Two Truths and a Lie
The 'Just Say No' Approach to Governing
Sabotaging Health Care, One Lie at a Time
The House Republicans' Ghoulish Defunding Rally
What's More Unpopular Than Health Care Reform?
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The New York Times
October 17, 2015 Saturday
Late Edition - Final
Careful Calculus Guides Obama Administration in Health Insurance Projections
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 992 words
WASHINGTON -- In April 2014, President Obama declared victory in the government's aggressive push to enroll people in private health insurance plans under the Affordable Care Act, announcing that eight million people had signed up for coverage.
''This thing is working,'' he said.
By the end of the year, enrollment was down to 6.3 million, but administration officials confidently predicted a 44 percent increase for 2015.
So it was surprising this week when Sylvia Mathews Burwell, the secretary of health and human services, predicted only slim gains in the coming year, millions below earlier projections. Ms. Burwell suggested that a huge campaign with thousands of field workers would be needed to keep enrollment at recent levels.
Why did the Obama administration set such a modest goal? It was part of an elaborate numbers game played for several years by proponents and opponents of the health law.
On the one hand, administration officials want to manage expectations in a presidential election year, when surpassing the goal will be better for Democrats than falling short. In this respect, federal officials are like corporate executives who smooth out earnings to meet or exceed projections given to investors.
On the other hand, health policy experts said, the enrollment goal for 2016 may be realistic. The White House aims to have 10 million people insured through the new marketplaces at the end of 2016, an increase of just 100,000 over the number enrolled in June of this year, and experts said it would not be easy to find and enroll people who have refused to sign up for the last two years.
Stan Dorn, a health lawyer at the Urban Institute, a nonprofit research group, said the enrollment goal was sensible. ''I am not optimistic that we will see more than that,'' Mr. Dorn said. ''The easiest people to reach have already signed up.''
Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group, said the administration's target was ''realistic but disappointing.''
The tax penalty for people who go without insurance will be higher next year: $695 for each adult or nearly 2.5 percent of household income, whichever is greater. That may encourage some people to enroll, Mr. Dorn said, but the cost of insurance is ''still an obstacle'' for some.
Hillary Rodham Clinton is the latest prominent politician to suggest that the Affordable Care Act is not so affordable for some people. A significant number fail to pay their monthly premiums or struggle with high out-of-pocket costs for medical services and prescription drugs.
The cautious calculus by the White House, as the administration gears up for the third open-enrollment period, from Nov. 1 to Jan. 31, tends to confirm perceptions of the health law that have been taking shape in the last two years. The expansion of Medicaid appears to be a more durable source of coverage than private insurance bought through the marketplaces.
Consumers with the lowest incomes receive the largest subsidies in the exchanges, and many have concluded that subsidized insurance is a good value. More than 80 percent of people using the federal exchange have incomes less than 250 percent of the poverty level (less than $29,425 a year for an individual). But marketplace coverage has been less attractive to people with higher incomes who receive less financial assistance.
One of the big questions raised by the new target is whether enrollment is reaching a point where it will remain stable.
''We're not seeing evidence of having plateaued,'' said Richard G. Frank, an assistant secretary of health and human services. But, he added, ''we are seeing a much longer path to long-term equilibrium in the market.''
The Congressional Budget Office predicted in June that enrollment through the exchanges would reach 20 million in 2016 and then level off around 22 million through 2025.
The White House accepted the budget office's estimate for 2014 as a goal, but now administration officials do their own analysis and projections, and they take issue with the office's numbers.
If the administration's prediction disappointed supporters of the health law, it was in part because the administration had pumped up expectations with several years of optimistic reports on enrollment trends and market dynamics.
The history of Medicaid, enacted in 1965, and the Children's Health Insurance Program, created in 1997, shows that it took years for them to gain momentum. Medicaid did not include all states until 1982, when Arizona joined. In a 2001 report, the Congressional Research Service said that ''until recently, there was general disappointment'' with the children's health initiative because of ''low enrollment rates early in the program.''
The program for children, now seen as a great success, was devised and adopted with broad bipartisan support from members of Congress and state officials.
By contrast, the Affordable Care Act was adopted without any Republican votes, and Republicans' continual criticism of it may sow doubts among consumers about its benefits.
''We've seen Republicans lie to the American public for years about it, and they've spent hundreds of millions of dollars to propagate those lies,'' said Josh Earnest, the White House press secretary. ''So the fact that there's a little bit of confusion is not surprising to me.''
Robert Laszewski, a consultant who works with insurance companies, said the goal announced Thursday by Ms. Burwell was astonishing and made him wonder, ''Has the Obama administration given up on Obamacare?''
''Enrollment of 10 million people is not sustainable,'' Mr. Laszewski said. ''You need almost twice that number to have a viable pool of policyholders with enough healthy people to pay for the sick.''
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URL: http://www.nytimes.com/2015/10/17/us/politics/careful-calculus-guides-obama-administration-in-health-insurance-projections.html
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December 15, 2014 Monday
Late Edition - Final
In Final Spending Bill, Salty Food and Belching Cows are Winners
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1036 words
WASHINGTON -- Health insurance companies preserved their tax breaks. Farmers and ranchers were spared having to report on pollution from manure. Tourist destinations like Las Vegas benefited from a travel promotion program.
Also buried in the giant spending bill that cleared the Senate on Saturday and is headed to President Obama for his signature were provisions that prohibit the federal government from requiring less salt in school lunches and allow schools to obtain exemptions from whole-grain requirements for pasta and tortillas.
The watered-down standards for school meals were a setback for the first lady, Michelle Obama, who had vowed to fight ''until the bitter end'' for tougher nutrition standards. But they were a victory for food companies and some local school officials, who had sought changes in regulations that are taking effect over several years.
When an omnibus spending bill pops onto the floor of the House or the Senate in the waning days of a congressional session, some lawmakers invariably express surprise and outrage at special-interest provisions stuffed into the package.
Representative Marcy Kaptur, Democrat of Ohio and a senior member of the House Appropriations Committee, criticized the $1.1 trillion spending measure as ''a Christmas tree bill,'' decorated with ''dangerous and unwelcome, nongermane riders.''
Such favors often have a long lineage. Lobbyists and lawmakers have, in many cases, been working on them for months or years. Some of this year's provisions originated as free-standing bills, languished on their own and were then revived in the spending package. Others block regulations that have been proposed, adopted and sometimes upheld in court.
The School Nutrition Association, representing cafeteria directors, welcomed the bill's language on sodium and whole grains. The lower sodium standards would have been ''extremely difficult to achieve,'' and the government needs more research before compelling schools to make such costly changes, said the association, which receives financial support from food companies.
Republicans like Representative Harold Rogers of Kentucky, the committee chairman, said the riders were needed to halt wasteful spending and ''overreach'' by agencies that generate rules harmful to the economy.
A typically arcane provision of the bill provides relief to nonprofit Blue Cross and Blue Shield plans, which have special tax breaks that were threatened by the Affordable Care Act.
Blue Cross is not mentioned by name in the relevant section of the 2015 spending bill, titled ''Modification of treatment of certain health organizations.'' But the deduction in question is available only to Blue Cross and Blue Shield plans, which have been lobbying Congress for a clarification since the Affordable Care Act was signed in 2010.
The National Cattlemen's Beef Association scored several victories that require the government to keep its regulatory hands off farms and ranches.
The bill says the government cannot require farmers to report ''greenhouse gas emissions from manure management systems.'' Nor can it require ranchers to obtain greenhouse gas permits for ''methane emissions'' produced by bovine flatulence or belching. The Environmental Protection Agency says on its website that ''globally, the agriculture sector is the primary source'' of methane emissions.
The spending bill requires the E.P.A. to withdraw a new rule defining how the Clean Water Act applies to certain agricultural conservation practices. It also prevents the Army Corps of Engineers from regulating farm ponds and irrigation ditches under the Clean Water Act.
''This is a major victory for farmers and ranchers, who consistently tell many of us that they are concerned about the potential of the E.P.A. and the Army Corps of Engineers' overreach into their operations,'' Representative Mike Simpson, Republican of Idaho, said.
The bill renews a travel promotion program championed by the Senate majority leader, Harry Reid, Democrat of Nevada, and by Las Vegas casinos.
''From the Las Vegas Strip to our pristine natural treasures like Lake Tahoe, tourists from all over the world want to visit Nevada,'' Mr. Reid said, and the legislation encourages them to do so.
But Senator Ted Cruz, Republican of Texas, blasted this as ''corporate welfare.''
''Last I checked,'' Mr. Cruz said, ''casinos were very profitable endeavors that didn't need the taxpayers helping them out.''
The bill provides more than $550 billion for national defense, including money for warplanes, missiles and submarines. But mundane military matters also drew attention. The bill is accompanied by a ''joint explanatory statement'' that gives thousands of directives to federal agencies.
One directive deals literally with boots on the ground. It orders the Defense Logistics Agency to re-examine the way it defines ''small business'' when buying boots and other military footwear. A supplier can qualify for advantages as a small business if it has no more than 1,000 employees. The number doubled in 2012.
Lawmakers fear that the new size standards could harm ''true small businesses'' and ''the domestic supply base for military footwear.'' Michigan's congressional delegation sought the legislative directive in response to concerns expressed by a Michigan company, Bates Footwear, which supplies combat boots and dress shoes to the military.
Steve Ellis, vice president of Taxpayers for Common Sense, a nonprofit research group that tracks federal spending, said the bill bestowed favors on all sorts of constituencies.
''Authors of the bill and lobbyists behind these provisions know they are in there,'' Mr. Ellis said. ''But the public will not find out about most of them for weeks or months, if ever.''
Congress supposedly forswore spending earmarks several years ago, after federal largess led to several scandals. But lawmakers can still steer money in less conspicuous ways.
For example, the 2015 spending bill authorizes additional money for an unnamed ''heritage area'' specified in Section 157 of title I of Public Law 106-291. That section of the law, enacted 14 years ago, established a national heritage area in Wheeling, W.Va., to celebrate the area's role in American history.
URL: http://www.nytimes.com/2014/12/15/us/politics/in-final-spending-bill-salty-food-and-belching-cows-are-winners.html
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GRAPHIC: PHOTO: A provision in the federal spending bill prohibits lowering salt limits for school lunches. (PHOTOGRAPH BY NABIL K. MARK/CENTRE DAILY TIMES, VIA ASSOCIATED PRESS) (A13)
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The New York Times
April 19, 2014 Saturday
Late Edition - Final
Obamacare Bashing or Bust
BYLINE: By CHARLES M. BLOW
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 17
LENGTH: 734 words
Thursday, President Obama delivered a compendium of positive news about the Affordable Care Act:
â- Eight million people have signed up for private health insurance.
â- Thirty-five percent of those signing up are under 35 years old.
â- The Congressional Budget Office now estimates that the cost of the law will be $100 billion lower than expected and will significantly shrink the deficit over the next 10 years.
''This thing is working,'' the president said. But it rang more as a lamentation than a proclamation. The health care law is a staggering achievement by this president and the Democrats and is likely to be viewed by history as such, but Republican opposition to it has been so vociferous and unrelenting that the president has been hard pressed to find a message that can overcome it.
Republicans repeat the same complaints, regardless of their veracity: Obamacare is bad for the economy and bad for Americans; it's an unwelcome expansion of government by an overreaching president; it's failing and will never work.
As Obama said Thursday:
''I find it strange that the Republican position on this law is still stuck in the same place that it has always been. They still can't bring themselves to admit that the Affordable Care Act is working. They said nobody would sign up; they were wrong about that. They said it would be unaffordable for the country; they were wrong about that.''
He continued:
''I know every American isn't going to agree with this law, but I think we can agree that it's well past time to move on as a country. ...''
But the president knows well that Republicans have no interest whatsoever in moving on. They've hitched their wagons to stop-Obama stallions and their plan is to race forward to Election Day.
The president smartly articulated the frustration that much of the opposition to the law in public opinion polls is ''attached to general opinions about me or about Democrats and partisanship in the country generally.''
The president's poll numbers took a hit during the health care rollout and have never fully recovered. The law also caused Democrats in general to lose their advantage in voters' preference for control of Congress, according to a CNN/ORC poll conducted in December. Furthermore, most Americans disapprove of the health care law.
The Republican plan is simply to hold tight to last year's disapproval and drag it forward to this year's election. And that just might work. Democrats have so fumbled the selling of the health care law's advantages, both moral and economic -- faltering and stammering when they should have been steadfast and resolute -- that they have acquiesced the debate to Republican opposition.
Rather than fight back with facts, too many Democratic politicians tucked their tails and ran away from the law, or, worse yet, joined the attack.
In addition to the effectiveness of Republican attacks and the anemia of Democratic support for the law, the demographics of midterm voters also bode well for Republicans.
Midterm elections generally skew older and whiter, and Republicans are counting on this skew to give them an electoral advantage. According to a Washington Post/ABC poll released at the end of last month, whites and elderly people are the least likely to support federal changes to the health care system, yet most elderly people are beneficiaries of another, quite successful government health care program: Medicare. And 77 percent of Medicare beneficiaries are white.
Even if Obamacare were not a factor, history suggests that this midterm election would still be a tough one for Democrats. As The Washington Post's Chris Cillizza pointed out in February:
''The party of a re-elected president tends to get walloped in the following midterm election. Since 1912 (that's when the House expanded to 435 seats), the president's party has lost an average of 29 House seats in the following midterm election.''
The health care law is working, insuring millions of Americans at far less a cost than what was previously estimated. But this civic victory may well contribute to a political defeat in November, unless Democrats can upend historical precedent and change the profile of the people who vote in off-year elections.
Our elections have been severely altered by a corporatist Supreme Court, maleficent voter ID laws and gerrymandering run amok. In the face of it all, can Democrats gather the gumption to say, ''Enough''?
URL: http://www.nytimes.com/2014/04/19/opinion/blow-obamacare-bashing-or-bust.html
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August 8, 2012 Wednesday
Too Conservative, or Just Extremely Conservative?
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 377 words
HIGHLIGHT: Meet Todd Akin, the Missouri Republican trying to unseat Claire McCaskill.
Ahead of Tuesday's G.O.P. primary in Missouri, Senator Claire McCaskill and her Democratic supporters spent around $2 million on ads describing one candidate, Representative Todd Akin, as too conservative for the state. Ms. McCaskill's hope was that Missouri Republicans would think "too conservative, sounds good!" and support Mr. Akin-in her estimation a relatively weak challenger. That strategy seems to have worked: Mr. Akin won last night's race with 36 percent of the vote.
She's taken quite a gamble. Whether Mr. Akin is "too" conservative is a matter of opinion, but certainly he's extremely conservative. (Or rather extremely right wing. The term "conservative" as it was once used doesn't really apply to 21st-century Republicans.)
This is a man who once called the president "a flaming socialist" and said that "America has got the equivalent of the stage three cancer of socialism." If the socialist cancer doesn't get us, he thinks marriage equality will: "anybody who knows something about the history of the human race," he once said, "knows that there is no civilization which has condoned homosexual marriage widely and openly that has long survived."
He backs up his bluster. In May, he proposed an amendment to the National Defense Authorization Act that would explicitly allow members of the Armed Forces to pick on gay personnel. As The Army Times put it, "Rep. Todd Akin is specifically aiming to protect religious freedom by allowing service members and chaplains to openly oppose gay and lesbian lifestyles and the presence of gay people in the ranks."
If, by some stroke of luck, neither gay marriage nor the generalized socialist cancer brings America down, Mr. Akin seems sure that the Affordable Care Act will. "It will destroy health care, and it will destroy our country if we don't stop it," he told a group of Tea Party activists last September. Lest anyone think that by "health care" he meant Medicare, he made clear that he "wasn't too comfortable" with that wildly popular program, either. "I don't find it in the Constitution that it is the job of the government to provide health care," he said.
If It Works in Israel...
Flip Flopping Away
Roberts Hits the Reset Button
Whatever Happens, I Will Have Reacted Already
Health Care Confusion
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The New York Times
July 1, 2012 Sunday
Late Edition - Final
What's On Sunday
BYLINE: By KATHRYN SHATTUCK
SECTION: Section MB; Column 0; Metropolitan Desk; Pg. 8
LENGTH: 725 words
8 P.M. (BET) BET AWARDS '12 The Rev. Al Sharpton will be honored for his humanitarianism, and the band Maze, featuring Frankie Beverly, for lifetime achievement at this 12th-annual ceremony honoring excellence by African-Americans and other minorities in entertainment and sports. Samuel L. Jackson, right, hosts this event, broadcast live from the Shrine Auditorium in Los Angeles. Marsha Ambrosius, Beyonce, Mary J. Blige, Melanie Fiona and Rihanna are nominated for best female R&B artist; Chris Brown, Bruno Mars, Miguel, Trey Songz and Usher for best male R&B artist; Big Sean, Drake, J. Cole, Lil Wayne, Rick Ross and Young Jeezy for best male hip-hop artist; Diamond, Nicki Minaj, Brianna Perry and Trina for best female hip-hop artist; and ASAP Rocky, Big Sean, Diggy, Future and Meek Mill for best new artist. Reporting from the red carpet starts at 6; an after-party follows at 11:30.
9 A.M. (CNN) STATE OF THE UNION WITH CANDY CROWLEY Ms. Crowley interviews Jacob J. Lew, the White House chief of staff, about the Supreme Court's ruling on the Affordable Care Act. Mr. Lew also appears on ''This Week With George Stephanopoulos'' alongside Victoria Kennedy, the widow of Senator Edward M. Kennedy, and Representative Paul Ryan, Republican of Wisconsin, at 10 on ABC, and on ''Fox News Sunday With Chris Wallace,'' at 10, where Senator Mitch McConnell, Republican of Kentucky, will discuss his party's efforts to repeal the Affordable Care Act.
10:30 A.M. (NBC) MEET THE PRESS Representative Nancy Pelosi, Democrat of California, discusses the Supreme Court's health care ruling and her party's election strategy. Gov. Bobby Jindal, Republican of Louisiana, and Howard Dean, the former chairman of the Democratic National Committee, weigh in.
10:30 A.M. (CBS) FACE THE NATION Norah O'Donnell speaks with House Speaker John A. Boehner about the health care ruling. Senators Charles E. Schumer, Democrat of New York, and Tom Coburn, Republican of Oklahoma, and the Governors Martin O'Malley, of Maryland, and Scott Walker, of Wisconsin, offer their perspectives.
7 P.M. (NBC) UNITED STATES OLYMPIC TRIALS Track and field finals, broadcast from Eugene, Ore., include the men's and women's 400-meter hurdles and 1,500 meter, and the men's 200 meter. The swimming finals, broadcast at 8 from Omaha, include the women's 200-meter backstroke and 800-meter freestyle, and the men's 100-meter butterfly and 50-meter freestyle. And at 9, the women's gymnastic finals will be broadcast from San Jose, Calif. Above, a scene from Friday's trials.
8 P.M. (OWN) OPRAH'S NEXT CHAPTER Oprah Winfrey interviews the Miami Heat players LeBron James, Dwyane Wade and Chris Bosh about their recent National Basketball Association championship and their friendship.
8 P.M. (13, 49) QUEEN & COUNTRY Using archival footage of Queen Elizabeth II, this four-part series celebrates her 60 years on the throne, starting with ''London: Royal City,'' which looks at the city as the center of a working monarchy. Trevor McDonald reports on the tradition of the changing of the guard at Buckingham Palace and visits the troops who protect the queen. In ''Endeavour,'' a ''Masterpiece Mystery!'' prequel to the ''Inspector Morse'' series, at 9, Shaun Evans plays the young Detective Constable Endeavour Morse, a rookie police officer on the verge of resigning until a schoolgirl is reported missing and presumed dead.
9 P.M. (CMT) RON WHITE'S COMEDY SALUTE TO THE TROOPS 2012 Mr. White, Kathleen Madigan, Jake Johannsen, John Pinette and Mike Wilmot pay tribute to those serving in the armed forces.
10 P.M. (Showtime) WEEDS Mary-Louise Parker, below, returns for her eighth and final season as a drug-dealing suburban mother, just as the shooting victim in last season's cliffhanger is rushed to the hospital. The Season 2 premiere of ''Episodes,'' at 10:30, finds Beverly and Sean Lincoln (Tamsin Greig and Stephen Mangan), the creators of a British television hit made unrecognizable by an American studio, suffering the repercussions of their collision with Matt LeBlanc (as himself).
10 P.M. (HBO) THE NEWSROOM In Episode 2 of this series about Will McAvoy (Jeff Daniels), a popular anchor who finally lets his opinions be heard, MacKenzie McHale (Emily Mortimer), his idealistic producer, assigns Sloan Sabbith (Olivia Munn), a beautiful economist, to do a segment. KATHRYN SHATTUCK
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June 22, 2012 Friday
Decoding Your Medical Bill
BYLINE: TARA SIEGEL BERNARD
SECTION: YOUR-MONEY
LENGTH: 462 words
HIGHLIGHT: This week's Your Money column discusses how difficult it has become for consumers to decipher how much they owe on their medical bills, and what those charges are based on.
This week's Your Money column looks at how difficult it's become for consumers to figure out how much they actually owe on their medical bills, and what the charges are based on to begin with.
I spoke with Jean Poole, a medical billing advocate, who talked about the 96 hours of detective work that was involved in untangling a 68-year-old man's medical bills after a long hospital stay -- and he was insured. Ultimately, she was able to uncover more than $22,000 in charges that he did not owe.
It's hard to shop around for good medical care because there's so little pricing information available. President Obama's Affordable Care Act, the health care overhaul law passed in 2010, tries to make some improvements (though the Supreme Court is expected to rule whether all or some of the law is constitutional this month).
But while the law's changes help you shop around for insurance policies -- specifically through its new one-stop-shop HealthCare.gov Web site, which lists all of your insurance options in one place -- it's still too soon to tell how effective the law will be for anyone comparing medical services.
For now, there are some helpful resources that already exist, which can provide you with a rough idea of what a service may cost in a specific geographic area, and many insurers also offer tools to their customers.
Fair Health's consumerWeb site provides estimated charges for different services, as well as what your insurer is likely to pay, along with your potential out-of-pocket costs based on different reimbursement rates set by insurance companies. It also allows you to estimate your out-of -pocket costs if your insurer bases its reimbursements on Medicare's payment schedule, Robin Gelburd, president of Fair Health Inc., said.
Health Care Blue Book's Web site allows you to search for different health care services and comes up with what it calls a fair price, or a price that many medical providers will accept, based on insurance claims and provider data.
Meanwhile, about 16 states are developing all-payer claims databases, known as A.P.C.D.s, using pricing information based on claims data collected from insurers, Medicaid and Medicare. And many have plans to create consumer Web sites based on that data, said Patrick Miller, founder of theA.P.C.D. Council. New Hampshire,Maine andMassachusetts have already created such consumer sites, though the information may not always be as specific or as comprehensive as you may like. For Florida residents, he said he also liked this site which provides pricing information for prescription drugs.
Have you tried to shop around for medical services? What was the experience like? And what sort of issues have you run into when attempting to figure out what you really owe on your medical bills?
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July 11, 2015 Saturday
Late Edition - Final
New Health Care Rules Are Issued for Companies Claiming Religious Exemptions
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 895 words
WASHINGTON -- The Obama administration issued new rules on Friday that allow closely held for-profit corporations like Hobby Lobby Stores to opt out of providing women with insurance coverage for contraceptives if the companies have religious objections.
Women enrolled in such health plans would still be able to get birth control at no cost, the administration said. Insurers would pay for contraceptive services, but the payments would be separate from the employer's health plan.
The rules came in response to a decision by the Supreme Court in June 2014. In that case, Burwell v. Hobby Lobby Stores, the court said that requiring family-owned corporations to pay for coverage of contraception under the Affordable Care Act violated a federal law protecting religious freedom.
The administration had argued against that conclusion, saying there was no precedent for granting ''a religious exemption'' to commercial enterprises like the Hobby Lobby craft stores.
But under the rules issued by the administration on Friday, certain for-profit businesses will be able to obtain an accommodation like the one already available to nonprofit religious groups, including Roman Catholic universities, hospitals and charities that object to covering the costs of contraceptives.
Contraceptive coverage has been the focus of fierce political debate for five years, as the administration struggled to meet the health needs of women while recognizing the concerns of people who have deep religious convictions against some or all forms of contraception.
Sylvia Mathews Burwell, the secretary of health and human services, said Friday that the new rules would ''secure women's access to contraceptive services while respecting religious beliefs.''
Family planning advocates, usually supportive of the administration, criticized the final rules.
Senator Patty Murray of Washington, the senior Democrat on the Senate health committee, said the rules allowed a wide range of businesses to have ''power over the health care decisions of the women they employ.'' The rules, she said, show why ''the Supreme Court's deeply harmful ruling in Burwell v. Hobby Lobby is completely unacceptable.''
Mrs. Murray is planning to introduce legislation to override the court decision. Senate Republicans blocked a similar bill last year and now, with more seats, could probably do so again.
Marcia D. Greenberger, co-president of the National Women's Law Center, a research and advocacy group, said, ''The rules go beyond the facts of the Hobby Lobby decision and will allow a broader set of for-profit employers to exempt themselves from the general requirement that contraception be covered as part of preventive health care for women.''
In an explanation of the rules, the administration confirmed that its definition of eligible closely held for-profit entities ''goes beyond what is required'' by the Hobby Lobby decision.
A study this week by researchers at the University of Pennsylvania estimated that women saved $1.4 billion a year on birth control pills because of the requirement in the Affordable Care Act for coverage of contraceptives without co-payments or other charges.
Under the law, employers with 50 or more full-time employees are generally required to offer health coverage or pay substantial penalties. Under a sheaf of rules issued in the last few years, such insurance must cover preventive services, including all forms of contraception approved for women by the Food and Drug Administration.
If they report their objections, and adhere to procedures described by the government, they can be excused from having to provide or pay for contraceptive coverage.
These companies can, in effect, opt out of providing or paying for contraceptive coverage. But their insurance carriers must, under the rules, make separate payments for contraceptives, so women would still have access to them, and insurers could be reimbursed by the government..
Relying on terms used in federal tax law, the rules define a ''closely held for-profit entity'' as a company that is not publicly traded and that has an ownership structure under which more than 50 percent of the ownership interest is held by five or fewer individuals.
Family members, including brothers, sisters and spouses, ''count as a single owner for purposes of these final regulations,'' the government said.
In addition, a closely held for-profit business may qualify if it has an ownership structure that is ''substantially similar'' to the one described in the rules.
Based on available data, the administration said it believed that its definition would encompass all the for-profit companies that have challenged the contraceptive coverage requirement on religious grounds. In addition, it predicted that at least 87 closely held for-profit businesses would try to opt out of providing contraceptive coverage.
To qualify under the rules, the ''highest governing body'' of a for-profit entity, such as the board of directors or trustees, must adopt a resolution certifying that ''it objects to covering some or all of the contraceptive services on account of the owners' sincerely held religious beliefs.''
Employers can register their objections by sending a letter to the government, or by sending a federal form directly to their insurers and the companies that administer their health plans.
URL: http://www.nytimes.com/2015/07/11/us/health-laws-contraceptive-rule-eased-for-businesses-with-religious-objections.html
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GRAPHIC: PHOTO: Protesters outside the Supreme Court last year after the Hobby Lobby decision, which permitted religious exemptions. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)
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March 23, 2015 Monday
Late Edition - Final
Ounce of Prevention: Health Care Systems Try to Cut Costs by Aiding Poor
BYLINE: By SABRINA TAVERNISE
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 1279 words
MINNEAPOLIS -- Jerome Pate, a homeless alcoholic, went to the emergency room when he was cold. He went when he needed a safe place to sleep. He went when he was hungry, or drunk, or suicidal.
''I'd go sometimes just to have a place to be,'' he said.
He made 17 emergency room visits in just four months last year, a costly spree that landed him in the middle of an experiment to reinvent health care for the hardest-to-help patients here in Hennepin County.
More than 11 million Americans have joined the Medicaid rolls since the major provisions of the Affordable Care Act went into effect, and health officials are searching for ways to contain the costs of caring for them. Some of the most expensive patients have medical conditions that are costly no matter what. But a significant share of them -- so-called super utilizers like Mr. Pate -- rack up costs for avoidable reasons. Many are afflicted with some combination of poverty, homelessness, mental illness, addiction and past trauma.
A patchwork of experiments across the country are trying to better manage these cases. The Center for Health Care Strategies, a policy center in New Jersey, has documented such efforts in 26 states. Some are run by private insurers and health care providers, while others are part of broader state overhaul efforts. The federal government is supporting some, too, through its $10 billion Innovation Center, set up under the Affordable Care Act.
They raise a new question for the health care system: What is its role in tackling problems of poverty? And will addressing those problems save money?
''We had this forehead-smacking realization that poverty has all of these expensive consequences in health care,'' said Ross Owen, a county health official who helps run the experiment here. ''We'd pay to amputate a diabetic's foot, but not for a warm pair of winter boots.''
Now health systems around the nation are trying to buy the boots, metaphorically speaking. In Portland, Ore., health outreach workers help patients get driver's licenses and give them essentials, such as bus tickets, blankets, calendars and adult diapers. In New York, medical teams are trained to handle eviction notices like medical emergencies. In Philadelphia, community health workers shop for groceries with diabetic patients
''This is a holy grail in research right now,'' said John Vu, a vice president at Kaiser Permanente, one of the largest insurers and care providers in the country. Kaiser has about two dozen projects in the United States, including in Denver, where medical teams screen for food insecurity.
Here in Hennepin, a fist-shaped county that encompasses Minneapolis, the pilot program is focused on about 10,000 people -- mostly men, all poor, some homeless -- who were covered when the state expanded Medicaid under the Affordable Care Act. It is paid for with state and federal Medicaid dollars and run by the county government and the safety-net hospital.
The aim is to fix patients' problems before they become expensive medical issues, so the county put its social services department to work. Its workers help people get phones and mailboxes, and take care of unpaid utility bills that otherwise could lead, for example, to insulin spoiling in nonfunctioning refrigerators. The project has even invested in a place where inebriated patients can sober up instead of going to the emergency room.
The idea -- to eliminate avoidable hospital use -- went against years of economic habit. Hospitals make money by charging per visit and procedure, and fewer of both would dent revenues. So the state offered a carrot: The hospital, Hennepin County Medical Center, a series of gray buildings and glass walkways, would be paid a fixed amount per patient and it would get to keep the money even if patients did not show up, or used less medical care than was paid for. The pilot program would work on caring for patients in places outside the hospital that are cheaper.
The arrangement, a stark departure from past practice, is increasingly common, part of the changes wrought by the health care law. The federal government has made similar deals with health systems for Medicare patients.
Some early experiments have found little or no savings in the short term. But in Hennepin County, medical costs have fallen on average by 11 percent per year since 2012 when the pilot program began, enough to keep it going and the hospital involved. Some of the biggest cost reductions were among the more than 250 patients who were placed into permanent housing.
The future of such efforts is uncertain. For programs that work to actually take root, more states and insurance companies may need to expand what they are willing to cover, for example, housing assistance, said Allison Hamblin, an expert at the Center for Health Care Strategies.
And it is unclear if private health systems -- which have little experience in taking care of social needs and still make most of their money per procedure -- will be as enthusiastic as Hennepin County Medical Center.
''We often hear comments that amount to 'Are you asking me to fight the war on poverty?' '' said Kelly W. Hall, a senior vice president at Health Leads, a nonprofit organization that helps medical teams connect patients to social services. ''But doing nothing is 'don't ask, don't tell' when it comes to the realities of patients' lives. People aren't comfortable with that either.''
Mr. Pate, 51, came to the Hennepin County hospital's emergency room last summer complaining of chest pains and thoughts of suicide. His arrival flickered on the screen of a social worker, Cerenity Petracek. She marched out to the emergency room to meet him.
''I was thinking 'Who is this person?' '' Mr. Pate recalled, noting that she was not wearing a doctor's coat. ''How's she supposed to help me?''
She spent over an hour with him and learned that he was homeless and addicted to cocaine and alcohol. She called around, found a treatment program that would accept him, helped him fill out the paperwork and then put him in a car to make sure he got there. A doctor later diagnosed a major heart blockage.
For the hardest-to-reach patients, there are outreach workers in the community. Such positions have been rare in health care because neither Medicare nor Medicaid would cover them. But the Affordable Care Act has opened up new ways to do so.
On a frigid morning in February, Prugh Jose, 42, a soft-spoken homeless man suffering from alcoholism and anxiety, called T.J. Redig, an outreach worker who was part of his medical team. Mr. Redig -- who wears stylish wool hats and writes novels in his spare time -- has a friendly, easygoing manner that earned Mr. Jose's trust.
Mr. Jose needed to get to the clinic for an appointment about his seizures (from a head injury on a construction job) but had forgotten the time for it. He had not eaten since the previous morning. His ex-wife offers him a couch when he can contribute food, but he had none, and spent the night outside.
''It was cold last night, Prugh,'' said Mr. Redig, 29, steering his dented green Pontiac onto the Interstate. He has even picked up Mr. Jose from the highway overpass where he panhandles.
''Yeah, really cold,'' Mr. Jose said. ''I went to see my buddies and stuff, but no one opened up.''
By the time Mr. Jose got to the clinic, he had missed his appointment. But he was gaining things that could help prevent an emergency later. A community health worker gave him a bag of food: frozen chicken, cereal and canned fruit. The receptionist handed him apple juice, which he used to take anti-seizure pills.
''Better,'' he said, after a long swig.
URL: http://www.nytimes.com/2015/03/23/health/taming-health-costs-by-keeping-high-maintenance-patients-out-of-the-hospital.html
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GRAPHIC: PHOTO: Prugh Jose, left, who is homeless, at the Hennepin County Medical Center's Dental and Oral Surgery Clinic in Minneapolis. (PHOTOGRAPH BY ANGELA JIMENEZ FOR THE NEW YORK TIMES)
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August 4, 2014 Monday
Late Edition - Final
Obama's Other Success
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 21
LENGTH: 795 words
Although the enemies of health reform will never admit it, the Affordable Care Act is looking more and more like a big success. Costs are coming in below predictions, while the number of uninsured Americans is dropping fast, especially in states that haven't tried to sabotage the program. Obamacare is working.
But what about the administration's other big push, financial reform? The Dodd-Frank reform bill has, if anything, received even worse press than Obamacare, derided by the right as anti-business and by the left as hopelessly inadequate. And like Obamacare, it's certainly not the reform you would have devised in the absence of political constraints.
But also like Obamacare, financial reform is working a lot better than anyone listening to the news media would imagine. Let's talk, in particular, about two important pieces of Dodd-Frank: creation of an agency protecting consumers from misleading or fraudulent financial sales pitches, and efforts to end ''too big to fail.''
The decision to create a Consumer Financial Protection Bureau shouldn't have been controversial, given what happened during the housing boom. As Edward M. Gramlich, a Federal Reserve official who warned prophetically of problems in subprime lending, asked, ''Why are the most risky loan products sold to the least sophisticated borrowers?'' He went on, ''The question answers itself -- the least sophisticated borrowers are probably duped into taking these products.'' The need for more protection was obvious.
Of course, that obvious need didn't stop the U.S. Chamber of Commerce, financial industry lobbyists and conservative groups from going all out in an effort to prevent the bureau's creation or at least stop it from doing its job, spending more than $1.3 billion in the process. Republicans in Congress dutifully served the industry's interests, notably by trying to prevent President Obama from appointing a permanent director. And the question was whether all that opposition would hobble the new bureau and make it ineffective.
At this point, however, all accounts indicate that the bureau is in fact doing its job, and well -- well enough to inspire continuing fury among bankers and their political allies. A recent case in point: The bureau is cracking down on billions in excessive overdraft fees.
Better consumer protection means fewer bad loans, and therefore a reduced risk of financial crisis. But what happens if a crisis occurs anyway?
The answer is that, as in 2008, the government will step in to keep the financial system functioning; nobody wants to take the risk of repeating the Great Depression.
But how do you rescue the banking system without rewarding bad behavior? In particular, rescues in times of crisis can give large financial players an unfair advantage: They can borrow cheaply in normal times, because everyone knows that they are ''too big to fail'' and will be bailed out if things go wrong.
The answer is that the government should seize troubled institutions when it bails them out, so that they can be kept running without rewarding stockholders or bondholders who don't need rescue. In 2008 and 2009, however, it wasn't clear that the Treasury Department had the necessary legal authority to do that. So Dodd-Frank filled that gap, giving regulators Ordinary Liquidation Authority, also known as resolution authority, so that in the next crisis we can save ''systemically important'' banks and other institutions without bailing out the bankers.
Bankers, of course, hate this idea; and Republican leaders like Mitch McConnell tried to help their friends with the Orwellian claim that resolution authority was actually a gift to Wall Street, a form of corporate welfare, because it would grease the skids for future bailouts.
But Wall Street knew better. As Mike Konczal of the Roosevelt Institute points out, if being labeled systemically important were actually corporate welfare, institutions would welcome the designation; in fact, they have fought it tooth and nail. And a new study from the Government Accountability Office shows that while large banks were able to borrow more cheaply than small banks before financial reform passed, that advantage has now essentially disappeared. To some extent this may reflect generally calmer markets, but the study nonetheless suggests that reform has done at least part of what it was supposed to do.
Did reform go far enough? No. In particular, while banks are being forced to hold more capital, a key force for stability, they really should be holding much more. But Wall Street and its allies wouldn't be screaming so loudly, and spending so much money in an effort to gut the law, if it weren't an important step in the right direction. For all its limitations, financial reform is a success story.
URL: http://www.nytimes.com/2014/08/04/opinion/paul-krugman-dodd-frank-financial-reform-is-working.html
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October 1, 2013 Tuesday
Senate Cancels First Hearing on Navy Yard Shooting
BYLINE: Ashley Southall
SECTION: US
LENGTH: 308 words
HIGHLIGHT: The first Congressional hearing focused on the Sept. 16 shooting at the Washington Navy Yard has been postponed indefinitely because of the government shutdown.
The first Congressional hearing focused on the Sept. 16 shooting at the Washington Navy Yard has been postponed indefinitely because of the government shutdown.
The hearing on Tuesday of the Senate Committee on Homeland Security and Government Affairs was to examine how the government grants clearance and conducts background checks, after a Navy contractor with a history of errant behavior killed 12 people at the complex.
Emily Spain, a spokeswoman for Senator Tom Carper of Delaware, the committee chairman, said it had not been rescheduled and warned of possible future postponements and cancellations.
"We'll be noticing - and potentially postponing - other hearings on a case-by-case basis moving forward until the shutdown situation is resolved," she said.
Other panels planned to move ahead with hearings scheduled for Tuesday.
The House Committee on Oversight and Government Reform is hearing testimony from officials at the Environmental Protection Agency about the case of John Beale. He pleaded guilty on Friday to "stealing nearly $900,000 from the agency over 13 years by failing to show up for work while falsely claiming to be working for the C.I.A. and for filing bogus expenses," according to The Associated Press.
The Senate Committee on Banking will look at the market for private-label mortgage-backed securities, while the Committee on Energy and Natural Resources will focus on the Transboundary Hydrocarbons Agreement with Mexico.
Democrats also planned to move ahead with events focused on the Affordable Care Act on Tuesday, as states open enrollment in health exchanges created under the law.
Obama Says He Isn't Resigned to a Shutdown
Disability Rights Group Rallies in Support of Health Law
House May Consider Short-Term Financing Measure
Republicans and Democrats Look for Compromise
Senate Rejects House Bill and Sends It Back
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July 23, 2015 Thursday
Morning Agenda: Bank of America Shake-Up
BYLINE: AMIE TSANG
LENGTH: 1716 words
HIGHLIGHT: Anthem Closes In on Cigna | Credit Suisse Back to Black | Chinese Investors Question Their Material World
BANK OF AMERICA SHAKE-UP | The lender's chief financial officer Bruce Thompson, has been abruptly replaced as part of a leadership overhaul, Michael Corkery reports in DealBook. He will be replaced by his deputy Paul Donofrio, a longtime Bank of America executive. Mr. Thompson had been mentioned as a possible successor to the chief executive, Brian T. Moynihan, but his departure will set off speculation about other potential candidates.
Mr. Moynihan has been under pressure recently because of regulatory slip-ups and financial results: The bank has struggled to generate consistent profits even as others have prospered. His management changes are a sign that he is moving to bolster his oversight of vital businesses.
Mr. Thompson's relationship with Mr. Moynihan had deteriorated recently, Bloomberg News reports, citing a person with knowledge of the situation who said the two disagreed about where to make tactical investments to boost revenue.
ANTHEM CLOSES IN ON CIGNA | The American health insurance market could soon shrink, Michael J. de la Merced reports in DealBook. Anthem, one of the biggest health insurers in the United States is nearing a deal to buy Cigna. It sweetened its previous takeover offer from $184 a share to $187 a share, people briefed on the matter said. This would value Cigna at about $48 billion.
Consolidation has swept across the health insurance industry as providers have pushed to pare costs and move into the government and individual markets. This possible deal comes just weeks after Aetna agreed to pay $37 billion for Humana, the smallest of the big five insurers. Analysts think that antitrust regulators will only allow a few mergers before deciding that power is too concentrated. Insurers have been spurred on by the Supreme Court's upholding the part of the Affordable Care Act that subsidizes consumers who buy policies through the government's online marketplace.
Eyes are now on UnitedHealth Group, the biggest of the American health insurers, to see what it plans to do next.
CREDIT SUISSE BACK TO BLACK | The Swiss bank returned to profit in the second quarter and beat expectations on the back of stronger results in the Asia Pacific region, Chad Bray reports in DealBook. Earnings in the second quarter rose to 1.05 billion Swiss francs, or about $1.09 billion, from a loss of 700 million francs in the same period last year. The second-quarter 2014 results took a hit from litigation charges and penalties related to a tax evasion case. Second-quarter results for 2015, however, received a boost from strong equity sales and trading, particularly in Asia Pacific. But they remain weak in fixed-income sales and trading, which were down on the quarter as market conditions weakened and uncertainty about Greece weighed on its foreign exchange and rates business.
Tidjane Thiam, the new chief executive since July 1, is expected to put his stamp on the bank in the coming months. He announced on Thursday that the bank had begun an "in-depth" strategic review of its operations and would look to make its portfolio "less capital intensive." Analysts think he might increase the emphasis on its wealth management operations, perhaps through the acquisition of an asset manager.
ON THE AGENDA | The Committee on Financial Services hearing, "Ending 'Too Big to Fail': What is the Proper Role of Capital and Liquidity?" starts at 10 a.m. After releasing its second-quarter results, General Motors will host a conference call to discuss them at 10 a.m. Visa and Amazon will discuss their quarterly earnings at 5 p.m. Mohamed El-Erian, chief economic adviser at Allianz, will be on CNBC at 10 a.m.
CHINESE INVESTORS QUESTION THEIR MATERIAL WORLD | Cheered on by relatives, co-workers and rapturous headlines in the state-run news media, ordinary investors in China have helped stoke a remarkable rally over the last year, Javier C. Hernández reports in DealBook. With easy access to loans for trading, individual investors opened more than 38 million stock accounts in the second quarter, compared with nine million in all of 2014.
China's saving rate may be among the highest in the world, but many Chinese also believe passionately in the power of luck. The intense interest in the stock market partly grew out of widespread social gambling. Many investors entered the market with lofty dreams of an exotic vacation or a new home.
The recent volatility in stock markets has unsettled these investors as they grapple not just with the financial toll, but also the loss of the emotional rush, especially as some saw the stock market as a way to define their worth. It seems in some cases, the people doing well out of the wild market movements are counselors and doctors helping sufferers of gupiao jiaolü zheng, or "stock market anxiety syndrome," Mr. Hernández and Vanessa Piao report in the Sinosphere blog.
One psychologist notes that counseling sessions for couples had turned remarkably civil as husbands and wives found a common enemy in the market.
| Contact amie.tsang@nytimes.com
Mergers & Acquisitions »
Pearson Close to Selling Financial Times | The British media and publishing company said it was nearing a deal for the newspaper with "a global, digital news company," Reuters reported.
NYT »
LeasePlan, a Dutch Fleet Manager, to Be Sold for $4.04 Billion | The German carmaker Volkswagen and the private banker Friedrich von Metzler have agreed to sell the fleet manager to a group of investors.
NYT »
St. Jude Medical to Buy Thoratec for $3.4 Billion | The transaction would bolster St. Jude Medical's business in treating heart failures by adding products and technologies, the company said.
NYT »
Abbott's Chief Supports Mylan's Bid for Perrigo | Abbott's chief executive said he considered the Perrigo acquisition to be in Abbott's interest as a shareholder in Mylan.
NYT »
Home Depot to Buy Interline Brands for $1.6 Billion in Cash | The deal for Interline Brands, a supplier of maintenance and repair products, is expected to bolster Home Depot's sales to the professional market.
NYT »
Walmart Takes Full Ownership of Chinese E-Commerce Venture | Walmart has taken ownership of Yihaodian, its Chinese e-commerce venture, solidifying the online retailer as a central part of its strategy in the region.
THE WALL STREET JOURNAL
Cisco Sells Set-Top Box Business | Cisco is selling off its set-top box business to Technicolor, based in Paris, for $600 million.
FORTUNE
UPS in Talks to Buy Coyote Logistics | UPS could pay $1.8 billion or more for Coyote, a provider of transportation and shipping services, The Wall Street Journal reports, citing people familiar with the talks.
THE WALL STREET JOURNAL
INVESTMENT BANKING »
Breakingviews: CIT Clears Way for Regional Bank Mergers | With the CIT Group's bid to acquire OneWest receiving regulatory approval, expect banking peers to test the $50 billion boundary.
Breakingviews » | Regulators Approve Merger of CIT and OneWest in $3.4 Billion Deal 1:44 AMNYT Now
Online Lender Prosper Makes Bank-Like Move | Prosper Marketplace, the second-largest online provider of consumer debt, is washing its hands of its least reliable customers by selling their loans to investors.
BLOOMBERG NEWS
PRIVATE EQUITY »
IRS Tries to Curb Private Equity Fee Waivers | The IRS is seeking to limit private-equity executives' practice of reducing their tax bills by reclassifying how their management fees are taxed.
BLOOMBERG NEWS
Private Equity Plays it Safe | The recent equity crash in China created cheap opportunities but buyout scouts would have had to set this against broader market dysfunction and the need to exit an investment eventually.
THE FINANCIAL TIMES
HEDGE FUNDS »
Bridgewater Flips View on China | The world's biggest hedge fund has turned on the world's fastest-growing economy and said, "There are now no safe places to invest."
THE WALL STREET JOURNAL
I.P.O./OFFERINGS »
China's Top Investment Bank Seeks Hong Kong Listing | China's leading investment bank has filed for an initial public offering in Hong Kong that could raise up to $1 billion, officially restarting a process that stalled last year with the departure of its chief executive.
THE FINANCIAL TIMES
Japan Post Shakes Up Sales Pitch Ahead of I.P.O. | Japan Post will present itself to potential investors as an "aggressive" asset manager of its $1.7 trillion investment portfolio as it prepares for a massive share offering this year.
THE FINANCIAL TIMES
VENTURE CAPITAL »
Netmarble Takes Stake in SGN, Extending Asia's Reach Into U.S. Mobile Games | In the last year, large Chinese and Japanese companies, including Tencent and Sega, have pumped tens of millions of dollars into American mobile gaming firms.
NYT »
Merck Pushing Frontier for RNA Medicines | Merck's early stage biotech investment arm has agreed to join The Baupost Group in leading a $55 million investment in the Cambridge, Mass.-based RaNA Therapeutics, which explores what some call the "dark matter" of the genome.
FORBES
Travel Start-Up Raises $6.5 Million | Beacon offers an all-you-can-fly service linking Boston and New York, and has raised $6.5 million in its first round of fund-raising and $1 million in debt financing.
THE WALL STREET JOURNAL
LEGAL/REGULATORY »
New York Seeks Information on Wall Street Messaging Platform | The state's top financial regulator is asking whether the platform developed by Symphony Communications could facilitate collusion among traders.
NYT »
Banamex USA Fined for Lack of Safeguards Against Money Laundering | Federal and state regulators said the bank, a unit of Citigroup, did not have adequate controls to detect illicit financial transactions.
NYT »
NYSE and Nasdaq Make a Pact | The New York Stock Exchange and Nasdaq OMX Group are planning an agreement to back up each other's closing auctions in the event of a disruption similar to the nearly four-hour trading halt at the New York Stock Exchange this month.
THE WALL STREET JOURNAL
Euronext wins court ruling over intellectual property | Euronext has won a court ruling in the Netherlands that prevents rivals from using the exchange operator's intellectual property to help run their own trading operations.
THE FINANCIAL TIMES
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LOAD-DATE: July 24, 2015
LANGUAGE: ENGLISH
DOCUMENT-TYPE: News
PUBLICATION-TYPE: Web Blog
Copyright 2015 The News York Times Company
All Rights Reserved
972 of 1000 DOCUMENTS
The New York Times Blogs
(News)
July 23, 2015 Thursday
DealBook: Bank of America Shake-Up
BYLINE: AMIE TSANG
LENGTH: 1716 words
HIGHLIGHT: Anthem Closes In on Cigna | Credit Suisse Back to Black | Chinese Investors Question Their Material World
BANK OF AMERICA SHAKE-UP | The lender's chief financial officer Bruce Thompson, has been abruptly replaced as part of a leadership overhaul, Michael Corkery reports in DealBook. He will be replaced by his deputy Paul Donofrio, a longtime Bank of America executive. Mr. Thompson had been mentioned as a possible successor to the chief executive, Brian T. Moynihan, but his departure will set off speculation about other potential candidates.
Mr. Moynihan has been under pressure recently because of regulatory slip-ups and financial results: The bank has struggled to generate consistent profits even as others have prospered. His management changes are a sign that he is moving to bolster his oversight of vital businesses.
Mr. Thompson's relationship with Mr. Moynihan had deteriorated recently, Bloomberg News reports, citing a person with knowledge of the situation who said the two disagreed about where to make tactical investments to boost revenue.
ANTHEM CLOSES IN ON CIGNA | The American health insurance market could soon shrink, Michael J. de la Merced reports in DealBook. Anthem, one of the biggest health insurers in the United States is nearing a deal to buy Cigna. It sweetened its previous takeover offer from $184 a share to $187 a share, people briefed on the matter said. This would value Cigna at about $48 billion.
Consolidation has swept across the health insurance industry as providers have pushed to pare costs and move into the government and individual markets. This possible deal comes just weeks after Aetna agreed to pay $37 billion for Humana, the smallest of the big five insurers. Analysts think that antitrust regulators will only allow a few mergers before deciding that power is too concentrated. Insurers have been spurred on by the Supreme Court's upholding the part of the Affordable Care Act that subsidizes consumers who buy policies through the government's online marketplace.
Eyes are now on UnitedHealth Group, the biggest of the American health insurers, to see what it plans to do next.
CREDIT SUISSE BACK TO BLACK | The Swiss bank returned to profit in the second quarter and beat expectations on the back of stronger results in the Asia Pacific region, Chad Bray reports in DealBook. Earnings in the second quarter rose to 1.05 billion Swiss francs, or about $1.09 billion, from a loss of 700 million francs in the same period last year. The second-quarter 2014 results took a hit from litigation charges and penalties related to a tax evasion case. Second-quarter results for 2015, however, received a boost from strong equity sales and trading, particularly in Asia Pacific. But they remain weak in fixed-income sales and trading, which were down on the quarter as market conditions weakened and uncertainty about Greece weighed on its foreign exchange and rates business.
Tidjane Thiam, the new chief executive since July 1, is expected to put his stamp on the bank in the coming months. He announced on Thursday that the bank had begun an "in-depth" strategic review of its operations and would look to make its portfolio "less capital intensive." Analysts think he might increase the emphasis on its wealth management operations, perhaps through the acquisition of an asset manager.
ON THE AGENDA | The Committee on Financial Services hearing, "Ending 'Too Big to Fail': What is the Proper Role of Capital and Liquidity?" starts at 10 a.m. After releasing its second-quarter results, General Motors will host a conference call to discuss them at 10 a.m. Visa and Amazon will discuss their quarterly earnings at 5 p.m. Mohamed El-Erian, chief economic adviser at Allianz, will be on CNBC at 10 a.m.
CHINESE INVESTORS QUESTION THEIR MATERIAL WORLD | Cheered on by relatives, co-workers and rapturous headlines in the state-run news media, ordinary investors in China have helped stoke a remarkable rally over the last year, Javier C. Hernández reports in DealBook. With easy access to loans for trading, individual investors opened more than 38 million stock accounts in the second quarter, compared with nine million in all of 2014.
China's saving rate may be among the highest in the world, but many Chinese also believe passionately in the power of luck. The intense interest in the stock market partly grew out of widespread social gambling. Many investors entered the market with lofty dreams of an exotic vacation or a new home.
The recent volatility in stock markets has unsettled these investors as they grapple not just with the financial toll, but also the loss of the emotional rush, especially as some saw the stock market as a way to define their worth. It seems in some cases, the people doing well out of the wild market movements are counselors and doctors helping sufferers of gupiao jiaolü zheng, or "stock market anxiety syndrome," Mr. Hernández and Vanessa Piao report in the Sinosphere blog.
One psychologist notes that counseling sessions for couples had turned remarkably civil as husbands and wives found a common enemy in the market.
| Contact amie.tsang@nytimes.com
Mergers & Acquisitions »
Pearson Close to Selling Financial Times | The British media and publishing company said it was nearing a deal for the newspaper with "a global, digital news company," Reuters reported.
NYT »
LeasePlan, a Dutch Fleet Manager, to Be Sold for $4.04 Billion | The German carmaker Volkswagen and the private banker Friedrich von Metzler have agreed to sell the fleet manager to a group of investors.
NYT »
St. Jude Medical to Buy Thoratec for $3.4 Billion | The transaction would bolster St. Jude Medical's business in treating heart failures by adding products and technologies, the company said.
NYT »
Abbott's Chief Supports Mylan's Bid for Perrigo | Abbott's chief executive said he considered the Perrigo acquisition to be in Abbott's interest as a shareholder in Mylan.
NYT »
Home Depot to Buy Interline Brands for $1.6 Billion in Cash | The deal for Interline Brands, a supplier of maintenance and repair products, is expected to bolster Home Depot's sales to the professional market.
NYT »
Walmart Takes Full Ownership of Chinese E-Commerce Venture | Walmart has taken ownership of Yihaodian, its Chinese e-commerce venture, solidifying the online retailer as a central part of its strategy in the region.
THE WALL STREET JOURNAL
Cisco Sells Set-Top Box Business | Cisco is selling off its set-top box business to Technicolor, based in Paris, for $600 million.
FORTUNE
UPS in Talks to Buy Coyote Logistics | UPS could pay $1.8 billion or more for Coyote, a provider of transportation and shipping services, The Wall Street Journal reports, citing people familiar with the talks.
THE WALL STREET JOURNAL
INVESTMENT BANKING »
Breakingviews: CIT Clears Way for Regional Bank Mergers | With the CIT Group's bid to acquire OneWest receiving regulatory approval, expect banking peers to test the $50 billion boundary.
Breakingviews » | Regulators Approve Merger of CIT and OneWest in $3.4 Billion Deal 1:44 AMNYT Now
Online Lender Prosper Makes Bank-Like Move | Prosper Marketplace, the second-largest online provider of consumer debt, is washing its hands of its least reliable customers by selling their loans to investors.
BLOOMBERG NEWS
PRIVATE EQUITY »
IRS Tries to Curb Private Equity Fee Waivers | The IRS is seeking to limit private-equity executives' practice of reducing their tax bills by reclassifying how their management fees are taxed.
BLOOMBERG NEWS
Private Equity Plays it Safe | The recent equity crash in China created cheap opportunities but buyout scouts would have had to set this against broader market dysfunction and the need to exit an investment eventually.
THE FINANCIAL TIMES
HEDGE FUNDS »
Bridgewater Flips View on China | The world's biggest hedge fund has turned on the world's fastest-growing economy and said, "There are now no safe places to invest."
THE WALL STREET JOURNAL
I.P.O./OFFERINGS »
China's Top Investment Bank Seeks Hong Kong Listing | China's leading investment bank has filed for an initial public offering in Hong Kong that could raise up to $1 billion, officially restarting a process that stalled last year with the departure of its chief executive.
THE FINANCIAL TIMES
Japan Post Shakes Up Sales Pitch Ahead of I.P.O. | Japan Post will present itself to potential investors as an "aggressive" asset manager of its $1.7 trillion investment portfolio as it prepares for a massive share offering this year.
THE FINANCIAL TIMES
VENTURE CAPITAL »
Netmarble Takes Stake in SGN, Extending Asia's Reach Into U.S. Mobile Games | In the last year, large Chinese and Japanese companies, including Tencent and Sega, have pumped tens of millions of dollars into American mobile gaming firms.
NYT »
Merck Pushing Frontier for RNA Medicines | Merck's early stage biotech investment arm has agreed to join The Baupost Group in leading a $55 million investment in the Cambridge, Mass.-based RaNA Therapeutics, which explores what some call the "dark matter" of the genome.
FORTUNE
Travel Start-Up Raises $6.5 Million | Beacon offers an all-you-can-fly service linking Boston and New York, and has raised $6.5 million in its first round of fund-raising and $1 million in debt financing.
THE WALL STREET JOURNAL
LEGAL/REGULATORY »
New York Seeks Information on Wall Street Messaging Platform | The state's top financial regulator is asking whether the platform developed by Symphony Communications could facilitate collusion among traders.
NYT »
Banamex USA Fined for Lack of Safeguards Against Money Laundering | Federal and state regulators said the bank, a unit of Citigroup, did not have adequate controls to detect illicit financial transactions.
NYT »
NYSE and Nasdaq Make a Pact | The New York Stock Exchange and Nasdaq OMX Group are planning an agreement to back up each other's closing auctions in the event of a disruption similar to the nearly four-hour trading halt at the New York Stock Exchange this month.
THE WALL STREET JOURNAL
Euronext wins court ruling over intellectual property | Euronext has won a court ruling in the Netherlands that prevents rivals from using the exchange operator's intellectual property to help run their own trading operations.
THE FINANCIAL TIMES
Sign up for the DealBook Newsletter, delivered every morning and afternoon.
LOAD-DATE: July 23, 2015
LANGUAGE: ENGLISH
DOCUMENT-TYPE: News
PUBLICATION-TYPE: Web Blog
Copyright 2015 The News York Times Company
All Rights Reserved
973 of 1000 DOCUMENTS
The New York Times Blogs
(News)
July 23, 2015 Thursday
Morning Agenda: Bank of America Shake-Up
BYLINE: AMIE TSANG
LENGTH: 1716 words
HIGHLIGHT: Anthem Closes In on Cigna | Credit Suisse Back to Black | Chinese Investors Question Their Material World
BANK OF AMERICA SHAKE-UP | The lender's chief financial officer Bruce Thompson, has been abruptly replaced as part of a leadership overhaul, Michael Corkery reports in DealBook. He will be replaced by his deputy Paul Donofrio, a longtime Bank of America executive. Mr. Thompson had been mentioned as a possible successor to the chief executive, Brian T. Moynihan, but his departure will set off speculation about other potential candidates.
Mr. Moynihan has been under pressure recently because of regulatory slip-ups and financial results: The bank has struggled to generate consistent profits even as others have prospered. His management changes are a sign that he is moving to bolster his oversight of vital businesses.
Mr. Thompson's relationship with Mr. Moynihan had deteriorated recently, Bloomberg News reports, citing a person with knowledge of the situation who said the two disagreed about where to make tactical investments to boost revenue.
ANTHEM CLOSES IN ON CIGNA | The American health insurance market could soon shrink, Michael J. de la Merced reports in DealBook. Anthem, one of the biggest health insurers in the United States is nearing a deal to buy Cigna. It sweetened its previous takeover offer from $184 a share to $187 a share, people briefed on the matter said. This would value Cigna at about $48 billion.
Consolidation has swept across the health insurance industry as providers have pushed to pare costs and move into the government and individual markets. This possible deal comes just weeks after Aetna agreed to pay $37 billion for Humana, the smallest of the big five insurers. Analysts think that antitrust regulators will only allow a few mergers before deciding that power is too concentrated. Insurers have been spurred on by the Supreme Court's upholding the part of the Affordable Care Act that subsidizes consumers who buy policies through the government's online marketplace.
Eyes are now on UnitedHealth Group, the biggest of the American health insurers, to see what it plans to do next.
CREDIT SUISSE BACK TO BLACK | The Swiss bank returned to profit in the second quarter and beat expectations on the back of stronger results in the Asia Pacific region, Chad Bray reports in DealBook. Earnings in the second quarter rose to 1.05 billion Swiss francs, or about $1.09 billion, from a loss of 700 million francs in the same period last year. The second-quarter 2014 results took a hit from litigation charges and penalties related to a tax evasion case. Second-quarter results for 2015, however, received a boost from strong equity sales and trading, particularly in Asia Pacific. But they remain weak in fixed-income sales and trading, which were down on the quarter as market conditions weakened and uncertainty about Greece weighed on its foreign exchange and rates business.
Tidjane Thiam, the new chief executive since July 1, is expected to put his stamp on the bank in the coming months. He announced on Thursday that the bank had begun an "in-depth" strategic review of its operations and would look to make its portfolio "less capital intensive." Analysts think he might increase the emphasis on its wealth management operations, perhaps through the acquisition of an asset manager.
ON THE AGENDA | The Committee on Financial Services hearing, "Ending 'Too Big to Fail': What is the Proper Role of Capital and Liquidity?" starts at 10 a.m. After releasing its second-quarter results, General Motors will host a conference call to discuss them at 10 a.m. Visa and Amazon will discuss their quarterly earnings at 5 p.m. Mohamed El-Erian, chief economic adviser at Allianz, will be on CNBC at 10 a.m.
CHINESE INVESTORS QUESTION THEIR MATERIAL WORLD | Cheered on by relatives, co-workers and rapturous headlines in the state-run news media, ordinary investors in China have helped stoke a remarkable rally over the last year, Javier C. Hernández reports in DealBook. With easy access to loans for trading, individual investors opened more than 38 million stock accounts in the second quarter, compared with nine million in all of 2014.
China's saving rate may be among the highest in the world, but many Chinese also believe passionately in the power of luck. The intense interest in the stock market partly grew out of widespread social gambling. Many investors entered the market with lofty dreams of an exotic vacation or a new home.
The recent volatility in stock markets has unsettled these investors as they grapple not just with the financial toll, but also the loss of the emotional rush, especially as some saw the stock market as a way to define their worth. It seems in some cases, the people doing well out of the wild market movements are counselors and doctors helping sufferers of gupiao jiaolü zheng, or "stock market anxiety syndrome," Mr. Hernández and Vanessa Piao report in the Sinosphere blog.
One psychologist notes that counseling sessions for couples had turned remarkably civil as husbands and wives found a common enemy in the market.
| Contact amie.tsang@nytimes.com
Mergers & Acquisitions »
Pearson Close to Selling Financial Times | The British media and publishing company said it was nearing a deal for the newspaper with "a global, digital news company," Reuters reported.
NYT »
LeasePlan, a Dutch Fleet Manager, to Be Sold for $4.04 Billion | The German carmaker Volkswagen and the private banker Friedrich von Metzler have agreed to sell the fleet manager to a group of investors.
NYT »
St. Jude Medical to Buy Thoratec for $3.4 Billion | The transaction would bolster St. Jude Medical's business in treating heart failures by adding products and technologies, the company said.
NYT »
Abbott's Chief Supports Mylan's Bid for Perrigo | Abbott's chief executive said he considered the Perrigo acquisition to be in Abbott's interest as a shareholder in Mylan.
NYT »
Home Depot to Buy Interline Brands for $1.6 Billion in Cash | The deal for Interline Brands, a supplier of maintenance and repair products, is expected to bolster Home Depot's sales to the professional market.
NYT »
Walmart Takes Full Ownership of Chinese E-Commerce Venture | Walmart has taken ownership of Yihaodian, its Chinese e-commerce venture, solidifying the online retailer as a central part of its strategy in the region.
THE WALL STREET JOURNAL
Cisco Sells Set-Top Box Business | Cisco is selling off its set-top box business to Technicolor, based in Paris, for $600 million.
FORTUNE
UPS in Talks to Buy Coyote Logistics | UPS could pay $1.8 billion or more for Coyote, a provider of transportation and shipping services, The Wall Street Journal reports, citing people familiar with the talks.
THE WALL STREET JOURNAL
INVESTMENT BANKING »
Breakingviews: CIT Clears Way for Regional Bank Mergers | With the CIT Group's bid to acquire OneWest receiving regulatory approval, expect banking peers to test the $50 billion boundary.
Breakingviews » | Regulators Approve Merger of CIT and OneWest in $3.4 Billion Deal 1:44 AMNYT Now
Online Lender Prosper Makes Bank-Like Move | Prosper Marketplace, the second-largest online provider of consumer debt, is washing its hands of its least reliable customers by selling their loans to investors.
BLOOMBERG NEWS
PRIVATE EQUITY »
IRS Tries to Curb Private Equity Fee Waivers | The IRS is seeking to limit private-equity executives' practice of reducing their tax bills by reclassifying how their management fees are taxed.
BLOOMBERG NEWS
Private Equity Plays it Safe | The recent equity crash in China created cheap opportunities but buyout scouts would have had to set this against broader market dysfunction and the need to exit an investment eventually.
THE FINANCIAL TIMES
HEDGE FUNDS »
Bridgewater Flips View on China | The world's biggest hedge fund has turned on the world's fastest-growing economy and said, "There are now no safe places to invest."
THE WALL STREET JOURNAL
I.P.O./OFFERINGS »
China's Top Investment Bank Seeks Hong Kong Listing | China's leading investment bank has filed for an initial public offering in Hong Kong that could raise up to $1 billion, officially restarting a process that stalled last year with the departure of its chief executive.
THE FINANCIAL TIMES
Japan Post Shakes Up Sales Pitch Ahead of I.P.O. | Japan Post will present itself to potential investors as an "aggressive" asset manager of its $1.7 trillion investment portfolio as it prepares for a massive share offering this year.
THE FINANCIAL TIMES
VENTURE CAPITAL »
Netmarble Takes Stake in SGN, Extending Asia's Reach Into U.S. Mobile Games | In the last year, large Chinese and Japanese companies, including Tencent and Sega, have pumped tens of millions of dollars into American mobile gaming firms.
NYT »
Merck Pushing Frontier for RNA Medicines | Merck's early stage biotech investment arm has agreed to join The Baupost Group in leading a $55 million investment in the Cambridge, Mass.-based RaNA Therapeutics, which explores what some call the "dark matter" of the genome.
FORBES
Travel Start-Up Raises $6.5 Million | Beacon offers an all-you-can-fly service linking Boston and New York, and has raised $6.5 million in its first round of fund-raising and $1 million in debt financing.
THE WALL STREET JOURNAL
LEGAL/REGULATORY »
New York Seeks Information on Wall Street Messaging Platform | The state's top financial regulator is asking whether the platform developed by Symphony Communications could facilitate collusion among traders.
NYT »
Banamex USA Fined for Lack of Safeguards Against Money Laundering | Federal and state regulators said the bank, a unit of Citigroup, did not have adequate controls to detect illicit financial transactions.
NYT »
NYSE and Nasdaq Make a Pact | The New York Stock Exchange and Nasdaq OMX Group are planning an agreement to back up each other's closing auctions in the event of a disruption similar to the nearly four-hour trading halt at the New York Stock Exchange this month.
THE WALL STREET JOURNAL
Euronext wins court ruling over intellectual property | Euronext has won a court ruling in the Netherlands that prevents rivals from using the exchange operator's intellectual property to help run their own trading operations.
THE FINANCIAL TIMES
Sign up for the DealBook Newsletter, delivered every morning and afternoon.
LOAD-DATE: July 24, 2015
LANGUAGE: ENGLISH
DOCUMENT-TYPE: News
PUBLICATION-TYPE: Web Blog
Copyright 2015 The News York Times Company
All Rights Reserved
974 of 1000 DOCUMENTS
The New York Times
June 7, 2016 Tuesday 00:00 EST
Boyce F. Martin Jr., Liberal U.S. Judge in Seminal Cases, Dies at 80
BYLINE: SAM ROBERTS
SECTION: US
LENGTH: 937 words
HIGHLIGHT: Judge Martin's rulings on affirmative action in college admissions and President Obama's health care law were affirmed by the Supreme Court.
Boyce F. Martin Jr., a defiantly liberal federal appellate judge whose rulings in two seminal cases - on favoring minority applicants in college admissions and on upholding President Obama's requirement that Americans buy health insurance - were upheld by the Supreme Court, died on June 1 at his home in Louisville, Ky. He was 80.
The cause was brain cancer, his son Boyce R. Martin III said.
In 2002, Judge Martin wrote for the majority in a bitterly divided United States Court of Appeals for the Sixth Circuit in Grutter v. Bollinger, the affirmative action case involving the University of Michigan Law School. (The court sits in Cincinnati and covers Kentucky, Ohio, Michigan and Tennessee.)
He ruled that higher education recruiters could seek a "critical mass" of black and Hispanic students to achieve racial, ethnic and intellectual diversity among their newcomers. The decision was affirmed by the United States Supreme Court, 5 to 4, in 2003, with Justice Sandra Day O'Connor writing the majority opinion.
Lee C. Bollinger, a former dean of the law school and then the incoming president of Columbia University, warned at the time that "a ruling that race and ethnicity could not constitutionally be considered in admissions would be drastic and disheartening, threatening a decline in minority enrollment of as much as 70 to 75 percent."
Judge Martin's decision in the health insurance case, in 2011, followed the first appellate review of the Affordable Care Act of 2010. His majority opinion for a three-judge panel upheld a lower-court ruling that Congress was empowered by the commerce clause of the Constitution to require that Americans purchase medical insurance.
A split Supreme Court, with Chief Justice John G. Roberts Jr. writing for the 6-to-3 majority, upheld the requirement, but said it was sanctioned by Congress's power to tax, not its authority to regulate interstate commerce.
While Judge Martin was generally a traditionalist in adhering to precedent, he peppered his opinions with citations from popular culture. He quoted Homer Simpson in an employment law case and the lyrics to the John Prine song "Paradise," about coal mining in Muhlenberg County, Ky., in an environmental ruling.
In 2012, he delivered a 19-page opinion extolling the singularity of Kentucky bourbon in affirming a trademark-infringement decision against Jose Cuervo, a tequila brand. His opinion for a unanimous appeals panel found that the red dripping wax seal on Cuervo's premium $100 Reserva de la Familia tequila bottles too closely resembled the signature coating that had covered the cap of Maker's Mark bourbon since 1958.
Quoting Justice Hugo Black, Judge Martin said he "was brought up to believe that Scotch whisky would need a tax preference to survive in competition with Kentucky bourbon" and declared, "All bourbon is whiskey, but not all whiskey is bourbon."
A fierce opponent of the death penalty and the author of an opinion voiding a Michigan law banning what abortion opponents call partial-birth abortions, Judge Martin drew fire from conservatives for his opinions and his judicial practices.
Danny J. Boggs, a fellow appeals judge, accused him of delaying a vote in the affirmative action case, in which the Sixth District court ruled, 5 to 4, until two conservative judges were no longer eligible to participate in the ruling.
An internal report by another appellate judge, Alice M. Batchelder, concluded that Judge Martin's conduct raised "an inference that misconduct has occurred," but no further action was taken. Judge Martin said Judge Batchelder's conclusion was "factually incorrect."
Judge Boggs also accused Judge Martin and his liberal colleagues of frivolously issuing stays of execution in capital punishment cases based on pretexts as flimsy as "a hot dog label."
But in a 2005 dissent, Judge Martin said that in his experience, "only one conclusion is possible: That the death penalty in this country is arbitrary, biased and so fundamentally flawed at its very core that it is beyond repair."
When Judge Martin retired in 2013 after 34 years on the Sixth Circuit court, an inquiry into his travel reimbursements, initiated by a conservative colleague, was referred to the Justice Department. The department decided not to pursue the complaint after Judge Martin voluntarily repaid the entire $138,500 he had received as reimbursements during a contested four-year period, even though, he said, only a fraction had been challenged.
Boyce Ficklen Martin Jr. was born in Boston on Oct. 23, 1935. His father was an assistant dean at Harvard Business School and an economics professor. His mother was the former Helen Artt.
He graduated from Davidson College in North Carolina with a bachelor of arts degree in 1957 and from the University of Virginia School of Law, which he attended while serving in the Army Reserve.
After serving as a federal prosecutor, teaching and practicing privately, Judge Martin was elected the first chief judge of Kentucky's newly created Court of Appeals. President Jimmy Carter nominated him to the federal appeals court in 1979. He was chief judge from 1996 to 2003.
His first wife, the former Mavin Hamilton Brown, died in 1997. They had four children. In addition to his son Boyce, he is survived by his second wife, the former Anne Brewer Ogden; another son, Robert C.G. Martin II; two daughters, Mavin H. Martin and Julie M. Hudson; eight granddaughters; a sister, Barbara Dudley; and a brother, W. Grier Martin.
PHOTO: Judge Boyce F. Martin Jr. was for decades a fierce liberal on the federal appellate bench. (PHOTOGRAPH BY CINCINNATI ENQUIRER, VIA ASSOCIATED PRESS)
LOAD-DATE: November 30, 2016
LANGUAGE: ENGLISH
DOCUMENT-TYPE: Obituary (Obit); Biography
PUBLICATION-TYPE: Web Blog
Copyright 2016 The New York Times Company
All Rights Reserved
975 of 1000 DOCUMENTS
The New York Times
December 1, 2016 Thursday 00:00 EST
What Republicans Should Know About the A.C.A.;
Taking Note
BYLINE: VIKAS BAJAJ
SECTION: OPINION
LENGTH: 370 words
HIGHLIGHT: Americans like it.
As President-elect Donald Trump and Republicans in Congress decide the future of the Affordable Care Act, they ought to pay close attention to a survey published on Thursday that shows that a large majority of the country supports the law's most important provisions.
Republican lawmakers and candidates have portrayed the 2010 law as an unmitigated disaster that must be repealed. But the new poll, which was conducted after the election by the Kaiser Family Foundation, shows that many Americans don't agree: 49 percent want the law expanded or implemented as it is and only 43 percent want it repealed or scaled back.
What is most interesting about the Kaiser survey is that individual provisions of the law are extremely popular. For example, 85 percent of those surveyed like the provision of the A.C.A. that allows young people to stay on their parents' health insurance plans until age 26; 80 percent support the subsidies the law provides to low- and moderate-income people who do not get insurance through employers; 80 percent are glad that the federal government helps states expand Medicaid to cover more poor people; and 69 percent like that the law prohibits insurers from denying coverage to people because of their medical history.
Critics of the law will point out that only 35 percent of the people Kaiser surveyed supported the provision that requires nearly all Americans to have health insurance or pay a fine. It is not hard to see why this provision is unpopular: Many people do not like being forced to do things, even things that are good for them. But the insurance mandate is a linchpin on which the benefits of the A.C.A. depend. If people were not required to buy insurance, many young and healthy people would not buy policies until they felt that they needed health care. That would drive up the cost of insurance in aggregate because insurers and the government would be left covering mostly older and sicker people.
Mr. Trump and Republican leaders in Congress seem determined to show their political base that they are going to repeal or substantially change the A.C.A.. But before they take a hatchet to the law, they should consider what most Americans think about what the law actually does.
LOAD-DATE: December 3, 2016
LANGUAGE: ENGLISH
DOCUMENT-TYPE: Editorial
PUBLICATION-TYPE: Web Blog
Copyright 2016 The New York Times Company
All Rights Reserved
976 of 1000 DOCUMENTS
The New York Times
January 14, 2016 Thursday
Late Edition - Final
In Kentucky, Abandoning Health Plan Sows Doubts
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1094 words
WASHINGTON -- There is no longer any question that Gov. Matt Bevin of Kentucky plans to shut down the health insurance exchange his state built to enroll residents for coverage under the Affordable Care Act. Now that he has notified the Obama administration of his intention to do so, the question is, will it change the law's substantial impact there?
It is hard to predict, partly because what Mr. Bevin is doing is without precedent. While a few states have been forced to largely rely on the federally run exchange after their own versions failed, Kentucky will be the first to abandon a homegrown exchange that functions well.
The federal exchange, HealthCare.gov, is running smoothly, and has in fact been more successful in enrolling new customers for 2016 than the 13 remaining state-based exchanges.
And while Kentucky has seen its uninsured rate drop more than that of any other state under the health law, some other states that have relied on the federal exchange have seen similar results.
The Obama administration has promised to work with Kentucky on a ''seamless transition'' to the federal exchange so that the roughly 81,000 residents who bought private health plans through the state one, Kynect, for 2016 will remain covered and others will be able to shop without a hitch. Jessica Ditto, a spokeswoman for Mr. Bevin, said that the transition could take place in time for the next open enrollment period, which starts in November, but that details had not been completed.
Still, supporters of the health law in Kentucky are worried. One concern, they say, is that some people will inevitably lose coverage during the switch to the federal exchange because they will get confused or annoyed or lost in the shuffle.
''We're concerned about this creating a perception that Kynect is failing,'' said Emily Beauregard, executive director of Kentucky Voices for Health, a coalition of advocacy groups. ''It's one more way to try to take the legs out from under the Affordable Care Act. But the truth of the matter is Kynect is working perfectly, and it's been good for Kentucky.''
A far bigger threat is Mr. Bevin's plan, still vague, to overhaul Kentucky's expansion of Medicaid, which has provided largely free health care to far more residents -- about 425,000 so far, or 10 percent of the population -- than have gotten private coverage through Kynect.
''The whole program is important to Kentuckians,'' former Gov. Steven L. Beshear said, ''but the Medicaid expansion is the part that must stay in effect to provide most Kentuckians with affordable health care.''
Mr. Bevin is no longer vowing to reverse the Medicaid expansion, as he did early in his campaign. But he says that with the state required to cover 10 percent of the cost by 2020, the program is unsustainable in its current form. He has talked about scaling back enrollment, among other things, although any changes would require the federal government's signoff. He said last month that he hoped to have a workable proposal by summer.
Mr. Beshear and other champions of the health law in Kentucky said Kynect, which the state received $290 million in federal grants to build, is easier to use than HealthCare.gov, and has added benefits that the federal exchange lacks. For example, the state determines which insurers participate under Kynect, and what the exchange plans look like and how much they will cost. Kynect has its own call center and coordinates outreach and enrollment efforts; it has become a well-known entity across the state, advertised on billboards, television and shopping bags, and in even the smallest rural newspapers.
Kynect is also the portal through which residents apply for Medicaid, and supporters say it will be more difficult to apply through the federal exchange, which will direct them to their state Medicaid office. Mr. Bevin has pointed out that Medicaid beneficiaries in Kentucky applied that way before Kynect opened in 2013. But Kynect, Ms. Beauregard said, streamlined the process significantly.
Another matter is the cost of shutting down Kynect. The Beshear administration estimated that it would be at least $23 million to dismantle the exchange, largely to ''de-integrate'' the software and technology used to enroll people in Medicaid and other safety-net programs.
Ms. Ditto, the governor's spokeswoman, said that based on a preliminary analysis, the Bevin administration believed that the cost would be ''substantially less.''
Another point that defenders of Kynect make is that its annual budget comes entirely from a 1 percent assessment on all insurance premiums in the state, which existed even before Kynect opened to pay for another insurance program. The federal exchange places a 3.5 percent assessment on all plans bought through it.
They say the higher assessment from the federal exchange could make premiums more expensive. But Ms. Ditto said the federal exchange's assessment would be fairer.
''The vast majority of Kentuckians are paying an assessment to support a website that they do not use,'' she said. ''This will ensure that the assessments are only applied to those using the exchange.''
Ms. Ditto said the Bevin administration did not anticipate having to pay back any of the $290 million in federal funds it received to build Kynect. But federal officials have suggested the state may need to repay $57 million the exchange has not yet spent.
Ms. Ditto also pointed out that the Beshear administration had planned to cut Kynect's outreach and marketing budget substantially starting next year, as the federal grant funds dried up. But Audrey Tayse Haynes, who ran the state's Cabinet for Health and Family Services under Mr. Beshear, said that made sense because the uninsured rate had dropped so much already.
Regardless, Mr. Beshear said he believed that the coverage gains the state had made would not erode once HealthCare.gov replaced Kynect, even though polls have consistently found Kynect to be more popular among its residents than the health law itself. Many, in fact, initially believed that Kynect was a program separate from the divisive health law, although Mr. Beshear said that perception had faded.
''Certainly I feel it will make it more difficult for Kentuckians to navigate the system and know what to do, which could reduce the number of people who are covered,'' he said. ''It's going to be the job of many of us who think Kentuckians having health care is all-important to make sure that doesn't happen.''
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URL: http://www.nytimes.com/2016/01/14/us/affordable-care-act-kentucky-insurance-exchange.html
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The New York Times
January 17, 2014 Friday
Late Edition - Final
Health Care Reform Survives a Lawsuit
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 24
LENGTH: 280 words
A long-shot lawsuit that could have damaged the effectiveness of health care reform got a well-deserved brushoff from a federal district judge on Wednesday. The suit was brought with the help of conservative legal groups and cheered on by Congressional Republicans eager to disable the Affordable Care Act.
The plaintiffs argued that the wording of the act allowed federal subsidies (in the form of tax credits) only for those buying insurance on the 14 health exchanges managed by a state, not on the exchanges established by the federal government in the 36 states that refused to set up their own. That contention was ridiculous on its face.
Judge Paul Friedman of the United States District Court for the District of Columbia, a Clinton appointee, dismissed the legal theory behind the lawsuit. ''The plain text of the statute, the statutory structure and the statutory purpose make clear that Congress intended to make premium tax credits available on both state-run and federally facilitated exchanges,'' Judge Friedman said in his ruling.
The law, he notes, was designed to provide quality, affordable health care for ''all'' Americans, not just those buying insurance on state-run exchanges. Similar lawsuits are pending in Virginia, Oklahoma and Indiana.
The wording could have been further clarified long ago if Republicans had been willing to cooperate in minor changes to the health reform law instead of trying to repeal or disable it. Instead, they are continuing to wage partisan warfare on this issue and others. The losing plaintiffs have vowed to appeal Judge Friedman's decision. Though they won't give up, Judge Friedman's well-reasoned decision deserves to be upheld.
URL: http://www.nytimes.com/2014/01/17/opinion/health-care-reform-survives-a-lawsuit.html
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The New York Times Blogs
(The Caucus)
June 26, 2012 Tuesday
Political Pitfalls in a Hasty Reaction to the Health Care Ruling
BYLINE: MICHAEL D. SHEAR
SECTION: US; politics
LENGTH: 823 words
HIGHLIGHT: The Supreme Court decision is likely to be a complicated and layered ruling that will require keen analysis and caution from political candidates.
Shortly after 10 a.m. on Thursday, the world will get its first reports from the United States Supreme Court about the fate of President Obama's health care law.
And if Monday was any indication, the initial result will be total confusion.
The political and media chatter that emerged in the moments after the court issued its ruling in the Arizona immigration case on Monday was all over the place.
The Associated Press reported that the case was a victory for Mr. Obama. Moments later, Reuters reported that Mr. Obama had suffered a political defeat in the ruling. Other organizations, including The New York Times, reported a mixed verdict.
And Twitter - which usually provides its users with scores of eerily similar musings - was a mass of contradictory exclamations. Some political activists blasted the court for striking down the law, while others trumpeted the court's decision to uphold it.
Bottom line? No one knew quite what to make of it.
And that was just the week's warm-up act. The big test comes on Thursday, when the court is expected to reveal its decision on the constitutionality of the Patient Protection and Affordable Care Act, the health care law that Republicans derisively call "Obamacare."
The Washington establishment will eventually figure out what has happened. There is, after all, an army of smart reporters, legal analysts, political heavyweights, industry executives, White House lawyers and experienced activists just waiting to pore over the decision when it is released.
But while they're doing that, the news cycle continues, unabated.
And unlike the immigration case, which was a fairly straightforward case involving up-or-down votes on four separate provisions, the health care ruling presents a series of complicated and interconnected questions.
Will the mandate to buy insurance be considered constitutional? If not, what happens to the related insurance provisions? Would the unconstitutionality of the mandate require that the entire law be struck down? If not, which parts can stand? And if it's a mixed bag, who benefits the most, politically?
There could be multiple dissents or concurring opinions from the justices, each with their own rationale for reaching the conclusions they did. Some of the justices may read statements from the bench, offering further elaboration - and more opportunity for confusion.
For the average reader, Web surfer or TV watcher, the uncertainty will be frustrating.
But the momentary chaos could be downright dangerous for political candidates who move too quickly to embrace or condemn the court's actions. A stray statement made before all the facts are understood could easily come back to haunt a political candidate.
In the White House race, Mitt Romney and President Obama are both preparing for any eventuality.
Mr. Romney's top advisers have been working with Republicans on Capitol Hill to coordinate the health care message, according to senior aides. Various scenarios have been sketched out and statements prepared.
Aides say they believe Mr. Romney can benefit politically no matter what the court decides.
At the White House, Mr. Obama's lawyers and political advisers are said to be preparing their own responses - both legal and political.
But the trick for both men will be to calibrate their statements appropriately in the moments after the decision is announced. And that won't be easy if the court's decision is a complicated one affecting different provisions in different ways.
Consider the risks.
If Mr. Romney immediately embraces a decision by the court to strike down parts of the law, he could later find himself on the defensive with independent voters for supporting the elimination of provisions that they liked.
Or Mr. Obama could issue a harsh critique of the court for rejecting parts of his legislation only to find later that major parts of it remain intact.
In the end, the political danger is likely to prompt a period of awkward silence from both camps in the first few hours after the ruling. That will give the campaigns a chance to digest the ruling, examine the opinions and come up with statements that are least likely to get them in trouble.
(In 2000, when the court issued its historic ruling in the Bush v. Gore case that gave the presidential election to George W. Bush, some top aides to the Texas governor described similar confusion. "I had the TV tuned to NBC," Karl Rove, a top aide to Mr. Bush, wrote in his memoir, "where legal affairs experts Pete Williams and Dan Abrams were delivering confused and uncertain reports on the decision.")
The rest of us won't be so lucky as to have a team interpreting the results. Until the full reports are filed by The Times's Adam Liptak and the other court reporters, we will have to rely on those initial reports on Twitter and the cable television channels.
Or, maybe we should just turn off the television and close down Twitter for a few minutes. It will probably be less frustrating.
LOAD-DATE: June 27, 2012
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(Taking Note)
September 5, 2014 Friday
Brandishing a Gun to Woo Voters
BYLINE: FRANCIS X. CLINES
SECTION: OPINION
LENGTH: 492 words
HIGHLIGHT: Firearm ads come and go as political staccato punctuating the electioneering season.
"They call me a long shot," Estakio Beltran, a congressional candidate in Washington state, declares in a TV ad, never once disclosing that he's a Democrat but taking aim with his shotgun at a piñata - an elephant piñata in case anyone doubts what he's gunning for. Bam! the gun goes off and the sad-eyed, paper-tattered toy elephant topples. Mr. Beltran's ad is one of many bamming and kerpowing across the land from candidates pandering to gun enthusiasts. He may not win an election, but his seems the most entertaining or at least the silliest. Particularly so when he racks the empty shell from his gun in macho triumph and rides off like Clint Eastwood, heading east toward the Capitol on a loping donkey (a Democratic donkey?).
Gun ads come and go as political staccato punctuating the electioneering season. They play out as an entirely separate reality from such familiar Americana as the accidental Uzi death last week at the hands of a nine-year-old in Arizona. The latest ads were collected by National Public Radio and, unsurprisingly, shooting a thick wad of "Obamacare" legislation is the cliché of choice among Republicans bearing arms. Will Brooke, a Republican congressional candidate in Alabama, has "a little fun," showing off his considerable arsenal of favored weapons - everything from gleaming pistol to ominous assault rifle - and shooting them all at what the Supreme Court has pronounced the law of the land. Joni Ernst, a leather-clad Republican running for Senate from Iowa, dismounts her motorcycle and gets off six rounds and a promise to "unload" on the Affordable Care Act. "Give me a shot!" she implores voters in her sign-off.
So it goes, to the point where Republicans choosing other sorts of targets provide merciful relief. Matt Rosendale, a Montana candidate for the House, blasts up and away at what he would have you believe is a federal drone snooping on his sacred freedoms. Dan Sullivan, an Alaska Republican running for the Senate, drills a defenseless old TV set, standing his ground against out-of-staters flooding the airwaves with mudslinging campaign ads.
So far, no one is making a commercial about the new Idaho law that allows teachers and students to bring guns to class. A professor exercising his "enhanced concealed carry" rights at the state university in Pocatello accidentally shot himself in the foot Wednesday.
But in truth, there are moments of substance in the politics of the gun. The ballot in Washington state has competing gun initiatives this fall, with rival check writers going at it to finance TV commercials. Initiative 594 aims to close the notorious loophole that lets people buy guns without background checks online and at gun shows. Backing it are such major donors as Bill and Melinda Gates and Nick Hanauer, the Seattle venture capitalist. In contrast, initiative 591 would prevent the expansion of background checks. The gun lobby stands behind this as the ballot duel plays out.
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December 16, 2014 Tuesday
Late Edition - Final
With Hospitals Under Stress, Tennessee's Governor Pursues Medicaid Expansion
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 737 words
WASHINGTON -- Under mounting pressure from financially strapped hospitals, Gov. Bill Haslam of Tennessee proposed on Monday an alternative plan for expanding Medicaid that he said would bring health coverage to tens of thousands more poor residents of his state without following traditional Medicaid rules.
Mr. Haslam, a Republican, made clear that he still opposed President Obama's Affordable Care Act, which encourages states to expand Medicaid to everyone earning up to 138 percent of the federal poverty level, or $16,105 for a single person. Nonetheless, he proposed using federal Medicaid funds available under the law to cover some 200,000 low-income residents through their employer's health insurance plan or the state's Medicaid program.
Under the second option, some people would be charged co-payments that are not always required by Medicaid, along with premiums that are rarely required. But they could receive help paying those costs ''by making healthy choices,'' Mr. Haslam said in a news conference in Nashville, such as by getting preventive screenings.
Mr. Haslam said the Obama administration had informally agreed to the plan last week after months of negotiations. But it still needs an official federal waiver and the approval of the Republican-controlled Legislature -- a potentially steep hurdle in a state where many lawmakers are aligned with the Tea Party and where opposition to Medicaid expansion has been strong.
Mr. Haslam said he would call a special session in January for lawmakers to consider the plan, adding, ''I believe something this important to Tennesseans should have a full discussion and its own focus.''
Katie Hill, a spokeswoman for the federal Department of Health and Human Services, said it had had ''productive discussions with Governor Haslam, and we look forward to the state submitting its plan.''
Ron Ramsey, a Republican who is the state's lieutenant governor and Senate speaker, and who in the past has adamantly opposed Medicaid expansion, suggested in a statement that he was open to the plan.
''Governor Haslam has negotiated a deal which returns tax dollars back to Tennessee while using conservative principles to bring health insurance to more Tennesseans,'' Mr. Ramsey said.
The state's two United States senators, Lamar Alexander and Bob Corker, both Republicans, also issued supportive statements.
If Mr. Haslam's plan receives the approval it needs, Tennessee will join 27 states that have expanded Medicaid under the Affordable Care Act, including nine with Republican leadership. Several other Republican governors have pushed for alternative forms of Medicaid expansion in their states since the November elections, partly a reflection of how badly hospitals and local communities want the federal funds that come with it.
''We now have several hospitals that have closed, and all the hospitals in the state are hurting to some extent,'' said Michele Johnson, the executive director of the Tennessee Justice Center, an advocacy group. ''It's creating more and more pressure, especially in some of those really rural, far-right Tea Party districts, to understand this in a different way.''
The tide may also be shifting in states like Utah and Wyoming, where Republican governors proposed their own versions of Medicaid expansion this fall, and in Idaho, where a group formed by Gov. C. L. (Butch) Otter is revising an expansion plan in hopes of winning legislative backing. The conservative governors of North Carolina and, most recently, Alabama, have expressed openness to expanding Medicaid programs if they can fashion their own approach.
In perhaps the most unusual part of Mr. Haslam's plan, the Tennessee Hospital Association has agreed to pay expansion costs beyond what the federal government covers. The Affordable Care Act calls for the federal government to cover all costs through 2016, with a gradually decreasing share thereafter, though never less than 90 percent.
Mr. Haslam described his proposal as a two-year pilot program that would need reauthorization.
Ms. Johnson said that some of the nation's largest for-profit hospital chains, including Hospital Corporation of America and Community Health Systems, have headquarters in Tennessee and have watched the amount they spend on uncompensated care drop this year in states that expanded Medicaid while it has risen in states like Tennessee. ''When they run the numbers, it's dramatic,'' she said.
URL: http://www.nytimes.com/2014/12/16/us/with-hospitals-under-stress-tennessees-governor-pursues-medicaid-expansion.html
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October 7, 2013 Monday
The International Herald Tribune
Republicans Put Forth Ugly Image
BYLINE: By ALBERT R. HUNT | BLOOMBERG VIEW
SECTION: Section ; Column 0; Foreign Desk; LETTER FROM WASHINGTON; Pg.
LENGTH: 997 words
WASHINGTON -- ''I am not a member of any organized political party,'' the humorist Will Rogers said. ''I am a Democrat.''
Even Rogers would be shocked at the disjointed and self-destructive congressional Republican Party of today. By forcing a government shutdown and possibly a credit default in a few weeks, a minority of rank-and-file Republican members have run roughshod over the leadership. They are pushing a futile effort to kill President Obama's health care law, enacted in 2010, upheld by the Supreme Court and hotly debated in last year's presidential campaign.
In so doing, this band of proud right-wingers has violated almost every important political precept, including:
HAVE AN ENDGAME In war, football, politics or other pursuits, it is incumbent to fight with an endgame in mind; sometimes the goal isn't achieved and needs adjusting. The Republicans forcing this crisis planned no endgame other than their hope that the president would cave in to their demand to gut the Affordable Care Act. Republicans like Bob Corker of Tennessee and John McCain of Arizona in the Senate, and Paul D. Ryan of Wisconsin and even Speaker John A. Boehner of Ohio in the House, warned that this was a fool's errand, to no avail.
The range of possible endgames now illustrates the chaos or lack of strategy: killing the medical-device tax, which would add $30 billion to the deficit over time; eliminating some government regulations; or mandating approval of the Keystone XL pipeline. This battle was supposed to be about curbing deficits and debt.
There is a sensible endgame: adopt a continuing resolution on the budget and extend the debt ceiling for several years. Congress then could replace the across-the-board discretionary spending cuts under sequestration with cutbacks in entitlements, including some means-testing and changes to cost-of-living adjustments for Social Security and other programs, as well as increased revenue from modest reductions in deductions for the wealthy, without raising rates.
This would narrow the already declining budget deficits slightly in the short run, more substantially down the road, and leave some money for smart investments in areas like infrastructure and health research. It's a good bet that markets and business confidence would soar after such a deal. With White House pressure, this would command support from a majority of congressional Democrats -- but not Republicans.
AVOID ANGER Many of the core Tea Party conservatives despise the president and are convinced that the health care law is an assault on freedom. Their stance reflects personal animosity as much as principle. Hard-right Tea Party types like Representatives Louie Gohmert of Texas, Steve King of Iowa, Michele Bachmann of Minnesota and Ted Yoho of Florida are in this category.
Regardless of whether the Affordable Care Act is better than the current system, it is not a government takeover, as is often charged; a public option was rejected by the White House and the Democratic Senate. Now opponents say the individual mandate amounts to government coercion. Yet the plan was originally a Republican idea and the centerpiece of Mitt Romney's successful health care program in Massachusetts when he was governor.
KNOW HISTORY The misinformation about previous conflicts is stunning.
Leading the chorus is former House Speaker Newt Gingrich, the Republican leader during the previous major partisan shutdown, in 1995-96. Mr. Gingrich has urged Republicans to hang tough, arguing that he and his party benefited from the earlier showdown.
In reality, it was a disaster. The Republicans lost two seats in the next House elections, and the deadlock paved the way for President Bill Clinton's big re-election. What did Mr. Gingrich get? Mr. Clinton agreed to provide the outlines of a long-term balanced budget, a commitment he relished. The subsequent balanced budgets had little to do with the shutdown.
Mr. Gingrich also claims this is nothing new, that shutdowns were routine when Speaker Tip O'Neill, a Democrat, was in charge. There were fights, but the government kept operating even when budget authority expired; when the attorney general ruled that impermissible, shutdowns occurred for several days, usually over a weekend, and were of little practical consequence -- until the Gingrich miscalculation of 1995-96.
PLAYING SHORT BALL Republican hard-liners insist that it won't hurt politically this time, never mind what the polls say. This showdown arouses the party's base, they argue, and will help candidates in next year's congressional elections.
Perhaps, but they confuse short-term gain with long-term damage, as occurred 17 years ago. Another example: In 1994, California Republicans rode a tide of anti-immigration sentiment to electoral victories but alienated Hispanics, which has cost them in elections since.
The shutdown and possible damage to the United States' creditworthiness are Republican-induced crises. The president is not blameless. The Republicans are able to keep the Affordable Care Act in political play because the administration has done such a poor job of persuading and educating voters; compare it with public attitudes toward Medicare or the prescription drug law three years after they were enacted.
Jack Danforth, the former Republican senator from Missouri, says the president and especially Harry Reid, the Senate majority leader, ''have too often told Republicans to go sit in the corner and be quiet; you're shut out of this.'' Still, he shakes his head at what he considers the naïve and dangerous attitude of Tea Party Republicans, that ''politics is not about compromise, it's about purity.''
Someone else whose head would shake is Will Rogers. In the Capitol Building's Statuary Hall, each state gets two statues; Rogers is one of Oklahoma's. The humorist's condition for allowing this was that his statue would be on the House of Representatives side so he could ''keep an eye'' on them. These days, he wouldn't want to look.
URL: http://www.nytimes.com/2013/10/07/us/republicans-put-forth-ugly-image.html
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(Taking Note)
November 15, 2013 Friday
Cutting the Heart Out of Health Reform
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 446 words
HIGHLIGHT: It’s hard to fathom why 39 Democrats voted for a bill that would allow people to retain substandard individual health care policies.
It's easy to be mad at President Obama over health care reform - the broken website, the confusing choices, his false promise that everyone could keep their current plans.
But it's still hard to fathom why 39 Democrats voted for a bill in the House that would allow people to retain current, substandard individual policies, and renew them next year even if they don't provide the basic coverage required by the Affordable Care Act. (You have to wonder, to start, whether they actually read the act before they voted for it, the same question I'd like to ask of Mr. Obama and his team. The changed requirements were in that law.)
Perhaps it was just a protest vote, a freebie based on the lawmakers' certainty that the Senate will never take up or pass this ridiculous bill. But did those Democrats know what they were voting for this time around?
It's impossible to accept the votes as a desire to fix the particular problem of people who got cancellation notices for individual plans.
For one thing, if those people could not get on the federal exchange, they might have been able to go to state-run exchanges but live in states where Republican governors refused to set them up. For another, the bill passed by the House today on a vote of 261-157 is not about providing a temporary fix. It is intended to cut the heart out of the health care reform program by allowing people to go on buying substandard policies next year.
Many of those policies are an illusion with catastrophically high deductibles and out-of-pocket spending ceilings. Take the insurance that the right-wing group Generation Opportunity was hawking last month. As Juliet Lapidos wrote here on Oct. 28, the $40.84 a month plan did not cover office visits for primary care doctors or specialists. It has a $10,000 a year deductible and if you ended up in the emergency room, you would have had to pay 20 percent of the bill after the deductible. The same applied to outpatient surgery and hospitalization.
There's another word for that - bankruptcy.
It may well be that insurance bought on the new exchanges costs more, but it will provide real coverage.
The insurance industry has already reacted to the idea of restoring cancelled policies, which Mr. Obama proposed on Thursday. It "threatens to undermine the new market, and may lead to higher premiums and market disruptions in 2014 and beyond," said Jim Donelon, Louisiana's insurance regulator.
So, if your Congressman is one of these 39 Democrats who voted for that mess today, you might want to ask why.
How the Shutdown May Hurt the Environment
Obama's Health Care Promise
Boehner's Last Stand
G.O.P. Helps Americans Like Government
Obama's Message to the Middle
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October 28, 2016 Friday
Late Edition - Final
Why We Need the Public Option
BYLINE: By JACOB S. HACKER.
Jacob S. Hacker, a professor of political science and director of the Institution for Social and Policy Studies at Yale, is an author of ''American Amnesia: How the War on Government Led Us to Forget What Made America Prosper.''
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTOR; Pg. 27
LENGTH: 1000 words
The Affordable Care Act has faced a rocky six months. First, major national insurers scaled back their participation, leaving about one in five people buying coverage through health exchanges with only one plan to choose from. Then this week, the Obama administration announced that exchange plans would post an average premium increase of more than 20 percent (though most enrollees would be insulated from the full increase by subsidies for their coverage).
As someone involved in the debate over the Affordable Care Act from the start, I don't find these unhappy events all that surprising. From the outset, I've argued that without a public option -- a Medicare-like plan that would be available to all Americans buying health insurance -- insurance competition would dwindle and premiums would skyrocket. Now that they have, it's time to do now what we should have done then: take the simplest route to a more stable and affordable health care system.
Critics of the public option are convinced it's a one-way ticket to single payer (the government alone provides coverage). History suggests the opposite: The public option isn't a threat to a system of broad coverage through competing private plans. Instead, it's absolutely critical to making such a system work.
We're already heading toward single payer in sections of the nation -- only it's a private plan doing the paying. Next year, five states will have only one insurer in their exchanges, the online marketplaces set up to allow uninsured Americans to buy subsidized coverage. Nine more states will have just two insurers.
The diminishing number of choices doesn't just hurt consumers; it also makes it harder for regulators to use antitrust tools to push back against this consolidation. Who wants to be the official accused of causing an insurer to leave the exchanges? It's a perverse equation: As the number of insurers goes down, the leverage they have over regulators goes up.
These problems are what motivated proposals for a public option in the first place. Major parts of the country lacked enough insurer competition to keep costs in line, especially with rapidly consolidating providers. And the proposed alternatives to a public option, like the insurance ''co-ops'' eventually included in the 2010 law, did not have the bargaining power and reach that a Medicare-like plan would have (and most of them have since gone out of business).
The argument by public-option supporters wasn't that it would or should replace private insurance. It was that having a public plan as a benchmark and backup was essential to make competition among private plans work. The models we have of successful competing health plans have a public or quasi-public option. That's true in Medicare, where private plans operate alongside the traditional program. And it's true in the federal employees' health system, where a majority of enrollees choose Blue Cross-style nonprofit plans that are overseen by the government to ensure they remain viable.
Having a public plan alongside private plans won't merely ensure that everyone has a choice. It will also pull more people into the system, creating a broader pool for all the plans. In polls conducted in 2009 and 2010, substantial majorities of Americans said they would feel better about being required to have coverage if they had the choice of a public plan.
A public plan is attractive in part because it can offer a broader network of providers. As exchange plans increasingly move toward very narrow networks, this would be another enormous draw -- especially for more affluent consumers who have so far shunned the exchanges.
The public plan can also improve the overall system. Medicare has pioneered innovations in reimbursement, and it has improved hospital quality by imposing new penalties for readmissions. A public option could build on these breakthroughs and extend them to Americans under Medicare age.
The biggest advantage of the public plan, however, is its greater ability to restrain prices. As rapidly as the insurance market is concentrating, medical providers are consolidating faster, driving up prices and creating huge differentials even within regions. Medicare hospital reimbursements vary much less -- and they're typically much lower. As a result, Medicare has experienced slower per-person cost growth than private plans, particularly in recent years.
On the other hand, private plans are much better poised to develop integrated systems that closely monitor outcomes for a smaller circle of providers. Just as in Medicare, public and private plans can complement each other as they compete.
The public option is an ambitious policy. But it's not hard to explain or advocate for -- Americans love Medicare -- and it has the potential to build powerful grass-roots support. Pressure from a coalition of left-leaning groups led by the Progressive Change Campaign Committee (a group that fought for the public option in 2009) has encouraged 33 Senate Democrats, including the party's leadership, to call for a public option. President Obama has started advocating for it again, and Hillary Clinton has embraced it.
Republicans have actually shown how it can be done. Changes in Medicare pushed by President George W. Bush in the 2000s created more competition between public and private plans and guaranteed a fallback public option for prescription drug coverage.
This year, Senate Republicans, providing another lesson, passed legislation that repealed the Affordable Care Act through the budget process, which isn't subject to a filibuster. (President Obama vetoed it.) If that's possible under the budget rules, creating a public option should be, too -- especially since it could reduce the deficit by tens of billions of dollars a year.
If things keep going as they are, Americans are certain to demand greater regulation of private plans to make them operate more like public plans. Instead, we should make them compete with a public option.
URL: http://www.nytimes.com/2016/10/28/opinion/the-best-way-to-save-obamacare.html
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July 7, 2015 Tuesday
Hillary Clinton Courts Bigger Crowds in Return to Iowa
BYLINE: AMY CHOZICK
SECTION: US; politics
LENGTH: 903 words
HIGHLIGHT: Hillary Rodham Clinton returned to one of the most liberal pockets of the state that shunned her in 2008, to speak at a public library packed with Iowans who ranged from curious to see the former first lady to committed to caucusing for her in next February’s contest.
IOWA CITY, Iowa - Hillary Rodham Clinton returned to one of the most liberal pockets of the state that shunned her in 2008, to speak at a public library packed with Iowans who ranged from those curious to see the former first lady to those committed to caucusing for her in next February's contest.
"I want people's lives to be better when I finish as your president than when I started," Mrs. Clinton told a crowd of roughly 350 people in remarks that ranged from foreign policy and economic issues to the drug epidemic and mental health.
The event marked the start of another phase in Mrs. Clinton's 2016 campaign in which she intends to speak to larger crowds and take more questions from voters in the early nominating states of Iowa and New Hampshire.
On Tuesday, Mrs. Clinton also sat down for an interview with CNN, her first with a national television outlet since she announced her candidacy official in April.
This liberal college town, home to the University of Iowa, that overwhelmingly favored Barack Obama and John Edwards in 2008 (she came in third statewide) could serve as a test of whether Mrs. Clinton's message resonates with the Democratic Party's base. Senator Bernie Sanders, a socialist who is also seeking the party's nomination, drew a crowd of 300 people at an event here in May.
In her speech, an animated Mrs. Clinton seemed to try to hit all the liberal notes, including combating climate change, giving women access to reproductive health care and celebrating the Supreme Court's recent decisions to legalize same sex marriage nationwide and uphold a key provision of Mr. Obama's health care overhaul.
"If a Republican is elected president, that will be the end of the Affordable Care Act," Mrs. Clinton said.
Her calls to make college more affordable played well in the almost all-white and largely female crowd. "How many of you had loans to go to higher education? I did, I did, so did Bill," Mrs. Clinton said. "I had like two jobs. He had like five. We were just working around the clock."
Despite pleas from liberal groups, Mrs. Clinton has not gone as far as Mr. Sanders, who said he would eliminate tuition at public colleges to reduce student debt.
Mrs. Clinton pushed for greater gun control measures, which contrasts her to Mr. Sanders, who has been one of the Democratic Party's most ardent defenders of Second Amendment rights. "Let's not be afraid of the gun lobby, which does not even really represent the majority of gun owners," she said.
After the event, Mrs. Clinton took questions from reporters. She called the collapse of the Greek economy a "tragedy" and called on European leaders to reach an agreement. And she declined to comment on a controversial provision of a nuclear agreement with Iran that would require the nation to disclose its previous nuclear experimentation, an issue that has divided the Obama Administration.
When asked about Mr. Sanders's surge in the polls, Mrs. Clinton said she always expected the race to be competitive. "It should be competitive. It's only the presidency of the United States we're talking about, so the more the better," she said.
After Iowa City, Mrs. Clinton headed to Ottumwa, Iowa, where she would talk to Iowans at a grassroots-organizing event. The campaign said it has already directly reached 16,000 Iowans and recruited at least one committed caucusgoer in each of the state's 1,682 precincts.
But Mrs. Clinton still has much to do in this state where voters expect to personally meet their candidates before participating in the famous caucuses, which take place Feb 1, 2016. Her lead over Mr. Sanders has narrowed in a recent poll - she still leads by double digits - and Iowans are clearly checking their options.
"I think I'm here out of curiosity more than anything else at this point," said Ashley Heffernen, 22, a recent graduate who waited in line with her boyfriend to hear Mrs. Clinton and hopefully ask a question about immigration. "I want t see all the candidates," Ms. Heffernen said.
Colleen Russo also waited in line outside the library. She supported Mr. Obama in 2008, but said she wanted to show her five-year-old granddaughter Viviana, who wore a pink dress and purple tiara, that a woman could be president. "She couldn't be more experienced," Ms. Russo said of Mrs. Clinton.
Jorge Guerra, 26, who stood next to the Ms. Russo and her grandchild, interjected: "Well, I'm glad you didn't bring her to see Michele Bachmann."
Mr. Guerra said part of what is holding him back from being all-in for Mrs. Clinton was her relationship to Wall Street and corporations. "It unnerves me," he said. "I want her to be as honest about and be as open as possible about a lot of these questions."
Ms. Russo agreed and said there were still things about Mrs. Clinton that gave her pause, but said Mrs. Clinton was most likely to win a general election. "I think she needs to be more exposed and talk to bigger groups, like Bernie does," she said, referring to Mr. Sanders. Mr. Guerra nodded. "She can't hide. Not someone like her."
Mrs. Clinton seemed acutely aware of how tough things may be for her in Iowa. After her remarks, she took questions from the audience. Dozens of hands went up.
"I'm gonna let you pick," she told the crowd. "Because I don't want to lose any potential caucusgoers."
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September 11, 2014 Thursday
Late Edition - Final
Stop the Anti-Obamacare Shenanigans
BYLINE: By HENRY J. AARON, DAVID M. CUTLER and PETER R. ORSZAG.
Henry J. Aaron is a senior fellow at the Brookings Institution. David M. Cutler is a professor of applied economics at Harvard. Peter R. Orszag, director of the Office of Management and Budget from 2009 to 2010, is a vice chairman at Citigroup.
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SO far, opponents of the Affordable Care Act have lost every major battle to repeal or invalidate it. Some of them are now urging the courts to interpret the health reform law in a way that would guarantee its failure. This is a significant threat -- potentially as grave as the previous main legal challenge to the law, which the Supreme Court rejected, 5 to 4, in 2012. If the new effort succeeds, it would create total chaos.
Having failed to undo the individual mandate to buy health insurance, opponents now claim that, under the law, subsidies for low- and moderate-income Americans to buy insurance may be paid only in those states -- currently 14 -- that have set up their own online insurance exchanges. This would torpedo a central goal of the law: the expansion of coverage.
At first, those of us who support Obamacare thought these claims were a joke. On July 22, the federal appellate court in Richmond, Va., rejected one such claim, but the same day, astonishingly, the federal appellate court for the District of Columbia Circuit ruled, 2 to 1, in favor of the plaintiff in a similar case, Halbig v. Burwell. Similar challenges are working their way through courts in two other circuits.
Last Thursday, the entire United States Court of Appeals for the District of Columbia Circuit put aside that 2-1 ruling, agreeing to hear the case ''en banc'' on Dec. 17. But now the opponents of Obamacare are asking the Supreme Court to immediately hear an appeal of the Richmond decision, and to pre-empt the full District of Columbia court from hearing the case.
The legal challenges say that a provision in the law that references the payment of credits to people who enroll through ''an Exchange'' that is ''established by a State'' means that credits are not available in the 36 states that have decided to have the federal government manage their exchanges for them.
We are economists, not lawyers. But we note that the statute, while vague at points, confirms, when read in its entirety, that tax credits are to be available on all the exchanges, nationwide. The law specifically instructed the secretary of health and human services to create and manage the exchanges for states that chose that option. And when the law was passed, everyone involved in the law's passage understood that this directive vested federal exchanges with the same mission and authority as state-mandated exchanges.
The expansion of coverage rests on interlocking elements. The law bars insurers from denying coverage to people with pre-existing medical conditions, dropping coverage when people develop costly illnesses, and charging discriminatory premiums. By themselves, these provisions would encourage people to delay buying insurance until they became ill, causing premiums to skyrocket. So to keep premiums affordable, the law requires nearly everyone to buy insurance, and offers low- and moderate-income people financial help -- in the form of refundable tax credits. If both the sick and the healthy buy insurance, premiums can be kept within reason.
Limiting tax credits to the 14 states that manage their own exchanges (along with the District of Columbia) would destroy this careful architecture. Over five million people receive coverage through federal exchanges -- two-thirds of all those covered through exchanges and 40 percent of those newly insured by the act. The best estimates suggest that out-of-pocket costs to typical enrollees of the least-expensive plans available in federally facilitated exchanges would soar to 23 percent of household income, from 3 percent -- and to 28 percent of income, from 6 percent, for those in the second least-expensive plans. Households would lose about $36 billion in tax credits that help make insurance affordable. Some 6.5 million fewer people would be insured. The federal exchanges could collapse, because they would be left with sick patients, saddled with costly premiums.
The record is unambiguous: Congress, in 2010, understood and endorsed the links connecting the sale of insurance, the requirement to carry insurance and the financial aid to make it affordable. Opponents who lost in the democratic process are now seeking to vitiate the law through a perverse reading of it.
If the full District of Columbia Circuit takes up the case, it should reject this sophistry. Meanwhile, the Supreme Court should wait to see what the lower courts do before deciding whether to intervene. Whatever one thinks of the Affordable Care Act, it is absurd to argue that its drafters intended to make insurance unaffordable.
URL: http://www.nytimes.com/2014/09/11/opinion/stop-the-anti-obamacare-shenanigans.html
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January 10, 2017 Tuesday 00:00 EST
Seven Questions About Health Reform;
Op-Ed Contributors
BYLINE: HAROLD POLLACK and TIMOTHY S. JOST
SECTION: OPINION
LENGTH: 987 words
HIGHLIGHT: Vague promises are not enough when we are considering enormous changes in our $3 trillion medical economy.
On Tuesday, Donald J. Trump said he wanted Congress to repeal the Affordable Care Act right away and replace it with a new plan "very shortly thereafter." But before they abandon all the work that has gone into the health care law since 2010, President-elect Trump and Republicans in Congress owe Americans a detailed explanation of how they plan to replace it. They should not repeal the law until they have submitted their replacement proposal for analysis by nonpartisan authorities like the Congressional Budget Office and the Tax Policy Center to determine how it will affect health insurance coverage, state and federal finances and individual tax burdens.
Vague promises are not enough when we are considering enormous changes in this country's $3 trillion medical economy. Here are seven important questions that Congress must answer about its replacement plan before repealing the Affordable Care Act:
1. How many millions of Americans will lose coverage? The A.C.A. expanded Medicaid coverage to around 12 million people in 31 states and the District of Columbia, and provided financial assistance for moderate-income Americans to buy insurance. These measures have reduced the percentage of Americans who are uninsured to the lowest levels in history. Proposals by Tom Price, Mr. Trump's choice to run Health and Human Services, and by the House speaker, Paul D. Ryan, would repeal the expansion of Medicaid and replace the A.C.A.'s income-based subsidies with less generous tax credits. Another plan from the House Republican Study Committee would offer deductions. We particularly need to know how this would affect low-income Americans, to whom tax deductions are nearly worthless, and who would generally not be able to afford coverage under these plans.
2. Will people over 55 pay higher health premiums for the same coverage? Under the health care law, premiums for older people cannot be more than three times as much as premiums for younger people. But the Ryanplan would let insurers charge older people five times as much. This change, combined with smaller tax credits or deductions that would not compensate for the increased cost, would significantly increase health care costs for many older Americans.
3. Will the new plan let insurers charge women higher premiums than men while offering them less coverage? Before the A.C.A. banned gender-based premiums, insurers in many states charged women more than men of the same age - some as much as 50 percent more. The A.C.A. also required all insurers to cover preventive health services without co-payments; for women, this includes birth control, Pap smears, mammograms and a host of other crucial services. Maternity care is fully covered as well. Republican replacement plans offer no such protection. And many Republicans want to defund Planned Parenthood, too, which would deprive women not just of coverage but also of care.
4. What other services are likely to be cut? Before the A.C.A., about a third of individual insurance market enrollees lacked coverage for the treatment of addiction, and nearly 20 percent lacked mental health coverage. One recent Republican proposal would require coverage only for hospital, physician and emergency care services. Will insurers be allowed to exclude any other services that they choose not to cover?
5. Will the new plan let insurers reinstate annual or lifetime limits on coverage? If so, how would the government ensure that individuals with life-altering illnesses and injuries received care without falling into financial ruin? Before the A.C.A., more than 50 percent of workplace insurance plans had lifetime limits, often in the range of $1 million to $2 million. That sounds like a lot - unless you are a 42-year-old man with leukemia. And "mini-med" policies often imposed annual limits of a few thousand dollars.
6. What will happen to the more than 130 million Americans with pre-existing conditions? Among the most important - and popular - provisions of the A.C.A. are its requirements that insurers cover and not charge higher premiums to people who have pre-existing conditions like cancer.
Some replacement plans propose segregating these people in high-risk pools. Before the A.C.A., two-thirds of states had such pools, which offered health plans with high premiums and deductibles and annual and lifetime caps. The pools never received enough support from the states to respond to the needs of high-cost individuals, and still covered only a tiny fraction of people with pre-existing conditions.
Other plans would protect individuals with pre-existing conditions from discrimination only if they maintained insurance coverage without any breaks. But this is not easy because of job loss and transient hardships. An estimated 44 million Americans experienced a gap in coverage of at least one month in 2013 or 2014.
7. Finally, how much more will those with costly illnesses or injuries have to pay in out-of-pocket costs? Critics of the A.C.A. often argue that the law has made health care unaffordable. But many Americans would pay much more without it. The A.C.A. capped out-of-pocket spending at $7,150 for individuals and $14,300 for families for 2017. Republican proposals appear to offer no protection from high deductibles and other cost-sharing.
This is a short list. One might ask many other important questions about changes to Medicare, Medicaid and insurance bought through employers. Before Congress leaps off the precipice of repeal, Americans have the right to ask, "Where will we land?"
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Harold Pollack is a professor of social service administration at the University of Chicago. Timothy S. Jost is an emeritus professor at Washington and Lee University School of Law and a contributing editor for the journal Health Affairs.
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April 11, 2014 Friday
Late Edition - Final
Sebelius Resigns After Troubles Over Health Site
BYLINE: By MICHAEL D. SHEAR; Robert Pear contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1425 words
WASHINGTON -- Kathleen Sebelius, the health and human services secretary, is resigning, ending a stormy five-year tenure marred by the disastrous rollout of President Obama's signature legislative achievement, the Affordable Care Act.
Mr. Obama accepted Ms. Sebelius's resignation this week, and on Friday morning, he will nominate Sylvia Mathews Burwell, the director of the Office of Management and Budget, to replace her, officials said.
The departure comes as the Obama administration tries to move beyond its early stumbles in carrying out the law, convince a still-skeptical public of its lasting benefits, and help Democratic incumbents, who face blistering attack ads after supporting the legislation, survive the midterm elections this fall.
Officials said Ms. Sebelius, 65, made the decision to resign and was not forced out. But the frustration at the White House over her performance had become increasingly clear, as administration aides worried that the crippling problems at HealthCare.gov, the website set up to enroll Americans in insurance exchanges, would result in lasting damage to the president's legacy.
Even last week, as Mr. Obama triumphantly announced that enrollments in the exchanges had exceeded seven million, she did not appear next to him for the news conference in the Rose Garden.
The president is hoping that Ms. Burwell, 48, a Harvard- and Oxford-educated West Virginia native with a background in economic policy, will bring an intense focus and management acumen to the department. The budget office, which she has overseen since April of last year, is deeply involved in developing and carrying out health care policy.
''The president wants to make sure we have a proven manager and relentless implementer in the job over there, which is why he is going to nominate Sylvia,'' said Denis R. McDonough, the White House chief of staff.
Last month, Ms. Sebelius approached Mr. Obama and began a series of conversations about her future, Mr. McDonough said. The secretary told the president that the March 31 deadline for sign-ups under the health care law -- and rising enrollment numbers -- provided an opportunity for change, and that he would be best served by someone who was not the target of so much political ire, Mr. McDonough said.
''What was clear is that she thought that it was time to transition the leadership to somebody else,'' he said. ''She's made clear in other comments publicly that she recognizes that she takes a lot of the incoming. She does hope -- all of us hope -- that we can get beyond the partisan sniping.''
Republicans seized on Ms. Sebelius's departure to heap even more criticism on the law she helped pass and carry out. ''No matter who is in charge of H.H.S., Obamacare will continue to be a disaster,'' said Reince Priebus, the chairman of the Republican National Committee. Senator Mitch McConnell of Kentucky, the Republican leader, said her resignation was ''cold comfort to the millions of Americans who were deceived about what it would mean for them and their families'' under the health care law.
The resignation is a low point in what had been a remarkable career for Ms. Sebelius, who as governor of Kansas was named by Time magazine as one of the five best governors in the country and was even mentioned as a possible running mate for Mr. Obama in 2008. The two had bonded when Ms. Sebelius endorsed his presidential bid early in 2008, becoming one of the highest-profile Democratic women to back him over Hillary Rodham Clinton, and helping him deliver a big win in the Kansas caucus.
White House officials were quick to point out the many successes during Ms. Sebelius's tenure: the end to pre-existing conditions as a bar to insurance, the ability for young people to stay on their parents' insurance, and the reduction in the growth of health care costs. In addition, Ms. Sebelius helped push through mental health parity in insurance plans and worked with the Department of Education to promote early childhood education.
Ms. Sebelius said in an interview on Thursday that she had always known that she would not ''be here to turn out the lights in 2017.''
''My balance has always been, when do you make that decision?'' she added.
The president had been under pressure for months to fire Ms. Sebelius. But he had resisted, in part because he did not want the Department of Health and Human Services to undergo more upheaval amid all the problems plaguing HealthCare.gov, and in part because of his general reluctance to publicly rebuke top officials.
In November, Mr. Obama defended the secretary, saying in an interview with NBC News that she ''doesn't write code; yeah, she wasn't our I.T. person.'' As recently as last week, Jay Carney, the White House press secretary, rejected any suggestion that Ms. Sebelius would be fired.
On Thursday, Mr. McDonough praised Ms. Sebelius as ''a fierce advocate,'' and said she had been ''tenacious in her belief'' in the president's health care law. ''She's fearless in her defense of this idea at the heart of the Affordable Care Act,'' he said. ''The president has commented to me countless times how much he admires that.''
But the Affordable Care Act faces a range of obstacles, political and otherwise, in the months ahead, and Mr. Obama is hoping that Ms. Burwell can smoothly steer the department and bring stability to its operations. In addition to the midterm elections, in which the health care law is the target of a flood of negative ads, the administration is grappling with policy questions: how it will levy the penalty on individuals who lack insurance, how much premiums will go up in the coming year, and how ultimately to administer the requirement that employers provide insurance.
Ms. Sebelius was not Mr. Obama's first choice to lead the department; he wanted former Senator Tom Daschle in the job, but Mr. Daschle withdrew after acknowledging that he had underpaid his taxes for several years. She was hailed as a gifted political leader in Kansas who could work with legislators of both parties. But those skills were less evident in Washington, and she became a more distant figure within the administration.
In addition to the political battles over the passage and carrying out of the Affordable Care Act, she clashed with conservatives over contraception, and faced frequent calls for her political head by Republicans after the health care website failed to function properly last year.
In hearings on Capitol Hill, Ms. Sebelius sometimes grew rattled under questioning by lawmakers. In one hearing at the end of October, Ms. Sebelius declared that HealthCare.gov ''has never crashed.''
''It is functional,'' she added, ''but at a very slow speed and very low reliability, and has continued to function.''
She made that statement even as large screens in the hearing room showed a live shot of the website with a page that said: ''The system is down at the moment. We are experiencing technical difficulties and hope to have them resolved soon.''
An appearance on ''The Daily Show With Jon Stewart'' last October went even worse. Mr. Stewart challenged her to ''sign up for Obamacare'' before he could download every movie ever made. ''We'll see which happens first,'' he joked. She struggled to defend the website and the law.
The television appearance prompted headlines like ''Kathleen Sebelius's 'Daily Show' Disaster'' and accusations from Republicans that she was being misleading. Democrats squirmed at her stiff and halting performance, which did little to inspire confidence.
But Ms. Sebelius has not been at the center of public attention in recent weeks. Her national television exposure has been limited after the poor public performances, but she has continued to make small appearances and has been active on Twitter to press for people to sign up for insurance. She submitted to another questioning before a Senate committee on Thursday and later acknowledged that the idea of not doing ''a hearing every three weeks sounds pretty good to me.''
The president's choice of Ms. Burwell to lead the Department of Health and Human Services places a relative outsider at the helm of one of the government's largest bureaucracies. Ms. Burwell has led the president's budget office since taking over for Jacob J. Lew, who is now the Treasury secretary.
Ms. Sebelius said she hoped -- but did not expect -- that her departure would represent the beginning of a more cooperative period in Washington to make health care better.
''If I could take something along with me,'' she said, it would be ''all the animosity.''
URL: http://www.nytimes.com/2014/04/11/us/politics/sebelius-resigning-as-health-secretary.html
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August 8, 2012 Wednesday
Romney Aide Touts Health Care Reform
BYLINE: TRIP GABRIEL
SECTION: US; politics
LENGTH: 380 words
HIGHLIGHT: The comments of a spokeswoman for Mitt Romney draw criticism from conservatives.
A principal message-maker of the Romney campaign drew criticism from conservative circles on Wednesday by suggesting that if a laid-off steel worker in an anti-Romney ad had lived in Massachusetts, he would have had health insurance and his wife might still be alive.
Andrea Saul, Mr. Romney's press secretary, meant to undermine a harsh ad by a "super PAC" supporting President Obama in which a man recounts how he his wife died from advanced cancer, implying the couple could not afford insurance because he had lost his job due to a plant shutdown tied to Bain Capital.
"To that point, if people had been in Massachusetts, under Governor Romney's health care plan, they would have had health care," Ms. Saul said on Fox News. "There are a lot of people losing their jobs and losing their health care in President Obama's economy."
Ms. Saul said the ad was "despicable" and a "smear" against Mr. Romney in trying to link the candidate to the woman's death. The steel worker in the ad, Joe Soptic, lost his job when a plant owned by Bain Capital, the private equity firm Mr. Romney co-founded, closed it in 2001. Mr. Soptic's wife died in 2006, shortly after being diagnosed, according to news reports.
The Romney campaign is furious with the ad, not least because Mr. Romney left Bain in 1999 and says he had no operational control after that.
But Ms. Saul's remarks threaten to upstage that message by reminding voters of the link between the president's health care law and Mr. Romney's Massachusetts health reform in 2006. The universal mandate to buy insurance that Mr. Romney promoted helped inspire President Obama's health care overhaul.
Mr. Romney has never repudiated his health care reform, but he has said it was right only for his own state, and he has vowed to repeal the Affordable Care Act if elected.
That pledge may be his most potent campaign message - when he repeated it in Iowa on Wednesday it drew the loudest applause of his speech. But reminders of his own role in inspiring Mr. Obama's law could work against him.
A number of conservative commentators were quick to jump on Ms. Saul's remarks. Erick Erickson, the editor of of the conservative website RedState.com, posted to his blog that it could be a "read my lips" moment that alienates grass-roots Republicans.
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The New York Times
May 29, 2013 Wednesday
The International Herald Tribune
States' Battle Against Health Care
SECTION: Section ; Column 0; Editorial Desk; LETTER; Pg.
LENGTH: 162 words
The fiscal, political and ideological barriers to health care in America are a national embarrassment, and the Affordable Care Act is a serious attempt to remove many of those barriers.
While the act does not solve all of our nation's health care problems, it is a far more effective and ethical approach to fixing health care than the highly objectionable behavior of those states opposing it. By obstinately refusing to expand their Medicaid program at virtually no cost to their state budgets, these states are recklessly imposing additional barriers to the welfare of millions. Hiding behind the Supreme Court decision affording the states the right to opt out of expanding Medicaid does not make it right to do so. These states' leaders reveal how they have wrongly prioritized their opposition to President Obama and his health plan over their constituents' access to health care.
Such negligence deserves our outrage and our condemnation.
Dr. Allan S. Lew, Los Angeles
URL: http://www.nytimes.com/2013/05/29/opinion/global/states-battle-against-health-care.html
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The New York Times
June 7, 2013 Friday
Late Edition - Final
The Spite Club
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 27
LENGTH: 801 words
House Republicans have voted 37 times to repeal ObamaRomneyCare -- the Affordable Care Act, which creates a national health insurance system similar to the one Massachusetts has had since 2006. Nonetheless, almost all of the act will go fully into effect at the beginning of next year.
There is, however, one form of obstruction still available to the G.O.P. Last year's Supreme Court decision upholding the law's constitutionality also gave states the right to opt out of one piece of the plan, a federally financed expansion of Medicaid. Sure enough, a number of Republican-dominated states seem set to reject Medicaid expansion, at least at first.
And why would they do this? They won't save money. On the contrary, they will hurt their own budgets and damage their own economies. Nor will Medicaid rejectionism serve any clear political purpose. As I'll explain later, it will probably hurt Republicans for years to come.
No, the only way to understand the refusal to expand Medicaid is as an act of sheer spite. And the cost of that spite won't just come in the form of lost dollars; it will also come in the form of gratuitous hardship for some of our most vulnerable citizens.
Some background: Obamacare rests on three pillars. First, insurers must offer the same coverage to everyone regardless of medical history. Second, everyone must purchase coverage -- the famous ''mandate'' -- so that the young and healthy don't opt out until they get older and/or sicker. Third, premiums will be subsidized, so as to make insurance affordable for everyone. And this system is going into effect next year, whether Republicans like it or not.
Under this system, by the way, a few people -- basically young, healthy individuals who don't already get insurance from their employers, and whose incomes are high enough that they won't benefit from subsidies -- will end up paying more for insurance than they do now. Right-wingers are hyping this observation as if it were some kind of shocking surprise, when it was, in fact, well-known to everyone from the beginning of the debate. And, as far as anyone can tell, we're talking about a small number of people who are, by definition, relatively well off.
Back to the Medicaid expansion. Obamacare, as I've just explained, relies on subsidies to make insurance affordable for lower-income Americans. But we already have a program, Medicaid, providing health coverage to very-low-income Americans, at a cost private insurers can't match. So the Affordable Care Act, sensibly, relies on an expansion of Medicaid rather than the mandate-plus-subsidy arrangement to guarantee care to the poor and near-poor.
But Medicaid is a joint federal-state program, and the Supreme Court made it possible for states to opt out of the expansion. And it appears that a number of states will take advantage of that ''opportunity.'' What will that mean?
A new study from the RAND Corporation, a nonpartisan research institution, examines the consequences if 14 states whose governors have declared their opposition to Medicaid expansion do, in fact, reject the expansion. The result, the study concluded, would be a huge financial hit: the rejectionist states would lose more than $8 billion a year in federal aid, and would also find themselves on the hook for roughly $1 billion more to cover the losses hospitals incur when treating the uninsured.
Meanwhile, Medicaid rejectionism will deny health coverage to roughly 3.6 million Americans, with essentially all of the victims living near or below the poverty line. And since past experience shows that Medicaid expansion is associated with significant declines in mortality, this would mean a lot of avoidable deaths: about 19,000 a year, the study estimated.
Just think about this for a minute. It's one thing when politicians refuse to spend money helping the poor and vulnerable; that's just business as usual. But here we have a case in which politicians are, in effect, spending large sums, in the form of rejected aid, not to help the poor but to hurt them.
And as I said, it doesn't even make sense as cynical politics. If Obamacare works (which it will), millions of middle-income voters -- the kind of people who might support either party in future elections -- will see major benefits, even in rejectionist states. So rejectionism won't discredit health reform. What it might do, however, is drive home to lower-income voters -- many of them nonwhite -- just how little the G.O.P. cares about their well-being, and reinforce the already strong Democratic advantage among Latinos, in particular.
Rationally, in other words, Republicans should accept defeat on health care, at least for now, and move on. Instead, however, their spitefulness appears to override all other considerations. And millions of Americans will pay the price.
URL: http://www.nytimes.com/2013/06/07/opinion/krugman-the-spite-club.html
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December 3, 2013 Tuesday
The Real Health Care Distraction?
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 344 words
HIGHLIGHT: President Obama said glitches were clouding the fact that the old insurance system wasn’t working, and that Republicans have no alternative.
In the last few weeks it's been trendy, in Republican circles, to claim that anything Democrats do or say unrelated to the Affordable Care Act is a ploy to "distract" attention away from the problematic HealthCare.gov rollout. (Really, anything: filibuster reform or a diplomatic breakthrough with Iran.)
In his speech today defending the law, President Obama seemed to try to take back that narrative, suggesting that all the attention paid to the glitchy rollout is the real distraction - from the fact that the law's working, the status quo ante was terrible, and that his political opponents have never offered a viable alternative.
On the first two points, it sounded as though he was speaking to the press. He said that "poor execution" had "clouded" the fact that people needed insurance, and that half-a-million people were "poised" to get insurance starting Jan. 1, even given the website's flaws.
On the third point, he was very obviously speaking to Republicans in Congress who, he said, were "rooting for this law to fail," but had no solution to offer in its place.
"If despite all the millions of people benefiting from it, you still think this law is a bad idea, you got to tell us specifically what you'd do different to cut costs, cover more people and make insurance more secure," the president said. "You can't just say the system was working with 41 million without health insurance."
Regarding the premise that the law's working, President Obama has some convincing to do. Public opposition to the law is growing. On the other hand, Americans are likely receptive to the criticism that Republicans are failure-rooters without alternatives, because they oppose repeal, too. Fifty-five percent of Americans think the law is either working well or that it has some good parts, but changes are needed to make it better - versus 43 percent who think it should be done away with entirely.
Talking Health Insurance Over Thanksgiving Dinner
No Budget, Because HealthCare.gov
Cutting the Heart Out of Health Reform
Obama's Health Care Promise
Boehner's Last Stand
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November 22, 2016 Tuesday
Late Edition - Final
If Obamacare Is Repealed, What Happens Then?
BYLINE: By AARON E. CARROLL and AUSTIN FRAKT; is a health economist with several governmental and academic affiliations.
SECTION: Section A; Column 0; National Desk; THE NEW HEALTH CARE; Pg. 3
LENGTH: 1116 words
The election of Donald J. Trump gives the Republicans in Congress a chance to act on their often-stated desire to get rid of Obamacare, a wish that Mr. Trump mostly says he shares. Aaron E. Carroll and Austin Frakt, the health policy analysts for The Upshot, discuss: Then what?
Aaron: I think it's safe to say few in Congress thought they would have this opportunity. But like the proverbial dog who has finally caught the car, after untold futile attempts, Republicans have finally come within reach of repealing the Affordable Care Act.
Now comes the essential question: Will they actually do it? They've been promising it forever, but I am still skeptical that it will happen. I believe you disagree. I'm going to let you go first. Why do you think they'll do it?
Austin: I think they'll do it because they so thoroughly own the idea of repeal, having passed bills to repeal, partly repeal, delay or defund the A.C.A. in the House something like 60 times. Just the other day Senator Mitch McConnell endorsed repeal (again). The House and Senate also agreed to do so, in large part, in a budget reconciliation bill earlier this year. The only thing that prevented it was that President Obama vetoed it. I doubt Mr. Trump would do the same if given a similar opportunity.
Now, I know that a budget reconciliation dismantling of the law is not a full repeal, because according to the rules it can only touch budget-related provisions. This excludes things like requiring insurers to take all comers for premiums that vary only by age and smoking status or preventing them from imposing coverage caps and lifetime limits, among other measures.
I also must add that I'm much less confident of a repeal (or partial repeal) without agreement on a replacement. But I'll turn it back to you, Aaron. Do you think the G.O.P. has to offer a full replacement to get its members to sign on to repeal? Or can it offer something that would cover fewer people and with fewer benefits?
Aaron: I think they can get away with slightly fewer people and somewhat skimpier benefits, but not too much. There's a part of me that thinks many in Congress were always so willing to vote for a ''repeal'' because they knew it had no chance of being signed into law. They got credit for the vote without ever having to face the downside. Actually repealing without replacing would mean effectively stripping more than 20 million people of their health insurance, without anything in return.
This would be an unmitigated political disaster. The stories -- of people with cancer, diabetes and more who were suddenly stripped of their insurance and left out in the cold -- would very likely dominate our discussion for months. That leaves more than enough time to lead to significant repercussions in the 2018 midterm elections. With no Democratic leaders in any branch of government to blame, I think this would be akin to what happened in the 2010 elections, but in reverse.
Now, if they can coalesce around a ''replace'' plan that doesn't leave too many people out, then I think they could move forward. But in all the years since the A.C.A. was passed, Republicans haven't been able to do that. Do you think they can? What do you think that plan would look like?
Austin: One way to get from repeal to replace that minimizes immediate political risk is to pass a plan that doesn't call for repeal for several years, at least after the 2018 midterms, though possibly after the 2020 election. Between now and then, there would need to be some kind of transition to whatever replaces Obamacare that didn't just dump people off coverage with no alternative.
But the alternatives could just be not as comprehensive or costly. Absolutely there will be bad stories. But keep in mind, there will be bad stories under Obamacare, too. Rocketing premiums, huge cost sharing and markets with few choices is not a recipe for political success. Republicans now own the task of fixing those things and doing so in a way that does not look as if they're making Obamacare better.
They're actually in a tough policy spot. They'll get the blame if they don't fix or repeal the A.C.A., and they'll get the blame if they don't replace it with something people like better. Health policy is a very difficult and thankless task. I think they'll opt for something they can call repeal and replace, but they could also just let Obamacare struggle and die. Neither looks good.
One other way to get out from under the issue is to kick it to the states. Do you think a Trump administration, working with a G.O.P. Congress, will offer greater flexibility to states to design their own coverage plans that could diverge from Obamacare? If so, what are some ideas states might try?
Aaron: I think it's very likely those in Congress could punt Medicaid to the states. For years, they've been trying to change Medicaid funding to a block grant that they can then constrain over time. This will be enticing for them because it will allow them to reduce Medicaid spending in the future, while forcing states to make the tough decisions -- and take the blame -- for cuts in either beneficiaries or services.
Fixing the markets for those who are getting health insurance through the Obamacare exchanges, though, is a different story. Without some sort of market regulation, which they've generally been opposed to, the same problems that existed pre-A.C.A. with respect to pre-existing conditions and individual ratings will exist. Many people will become uninsured. Annual and lifetime limits could reappear. Lots of people will have problems getting insured.
Moreover, I have yet to be convinced that a significant number of Republicans in the House might coalesce around such a plan. Maybe for Medicaid, but I'm not sure about the exchanges. Even if they could, it's likely the Democrats in the Senate would try to filibuster either of these plans. Don't you think?
Austin: Yes, I think Democrats would filibuster anything they could. The filibuster is not set in stone. A Senate majority can change it, and some are already calling for the G.O.P. to do so. But that doesn't appear to be what the Senate will do -- they'll retain the filibuster. This could play to their favor, since they can propose things they like, let the Democrats filibuster them and take the blame when repeal kicks in with no replacement. Perhaps that's another way for Republicans to get out of their political bind.
Aaron: I'm sure we'll have more to discuss as President Trump's administration comes into power.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
URL: http://www.nytimes.com/2016/11/22/upshot/lets-say-obamacare-is-repealed-what-then.html
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December 3, 2013 Tuesday
Late Edition - Final
Underachieving Congress Appears in No Hurry to Change Things Now
BYLINE: By JONATHAN WEISMAN
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1124 words
WASHINGTON -- The House straggled back to the Capitol on Monday night with just two weeks left before its likely entry into the Congressional record book for underachievement, still clinging to hopes that deals can be reached in the coming days on a budget and other once-routine bills that could ease some of the sting.
But even those accomplishments could be thwarted by a basic political calculation: Many Republicans believe they are getting such good traction from their attacks on President Obama's stumbling health care law that they feel less compelled to produce results. Any public fight over legislative compromises could take away from the focus Republicans have kept on the health care law.
''I ran on a government that did less,'' said Representative Reid Ribble, Republican of Wisconsin. ''I felt the government was overreaching, and the citizens that sent me didn't want me to be overaggressive in writing new laws. The Affordable Care Act launch is actually demonstrating the ineptitude of the federal government in handling these big programs.''
The 113th Congress has passed all of 55 laws so far this year, seven fewer at this point than the 112th Congress -- the least productive Congress ever. House and Senate negotiators will meet on Wednesday to try to come to terms on a farm bill, but they remain far apart, especially on food-stamp cuts that the House is demanding. The leaders of the House and Senate budget committees will also meet this week, and they appear to be closing in on a modest deal that would set spending levels for the next two years while relieving some of the pain from the across-the-board spending cuts known as sequestration.
In the meantime, the House is set to pass legislation on Tuesday to mandate that loose change left at airport security checkpoints be given to airport ''places of rest and recuperation'' for members of the armed forces. The real action will be off the House floor -- four different hearings in four different committees on the Affordable Care Act.
That contrast -- between tamping down expectations for legislative accomplishments and raising hopes of more health care fireworks -- has dominated Congress for more than a month.
''Republicans are using their political attacks on the Affordable Care Act as cover to do nothing else,'' said Representative Chris Van Hollen of Maryland, the senior Democrat on the House Budget Committee.
It is not as if there is nothing to do. If agreement cannot be reached on a farm bill by the end of the month, an agricultural system in place for decades will suddenly cease. The price of milk is set to skyrocket. Lawmakers were given until Dec. 13 to reach a deal on spending and taxation. That would give the House and Senate Appropriations Committees enough time to pass spending legislation by Jan. 15 to avert another government shutdown.
Congress is flirting with failing to pass its annual Pentagon policy bill for the first time in 52 years. This time around, the bill was set to address major military concerns, from sexual assault to the prison at Guantánamo Bay, Cuba.
And if Congress fails to act on what is commonly known as the ''doc fix'' before breaking for the year, reimbursements for medical care providers treating Medicare recipients will be cut sharply next year.
Even final agreement on a waterways-construction bill, which passed both houses of Congress overwhelmingly and has no money attached to it, appears to have slipped from reach this year.
''It speaks to the larger dysfunction in Washington right now,'' said Representative Charlie Dent, Republican of Pennsylvania. ''Washington is largely broken.''
At the same time, major bills passed by the Senate with bipartisan majorities to overhaul the nation's immigration laws, update farm programs, allow states to collect sales taxes from online retailers and protect lesbian, gay, bisexual and transgender people from workplace discrimination have been blocked from votes in the House -- where members of both parties say they could pass.
''At some point, the Republican leadership has to ask itself, 'Why are they here?' '' said Representative Jim McGovern, Democrat of Massachusetts, a negotiator on the farm bill. ''These are things that really need to get done.''
For their part, House Republicans say they have passed 149 bills awaiting Senate action, including some with bipartisan appeal, including legislation to construct the Keystone XL oil pipeline, upgrade cybersecurity and tighten sanctions on Iran. On Tuesday, the House will pass legislation extending a ban on the manufacturing of guns that can evade metal detectors. Next week, Representative Eric Cantor of Virginia, the majority leader, will push legislation to move political convention funding to pediatric health research -- a small part of a broader agenda to boost the Republican Party's appeal to women and minority voters that has largely stalled.
The House is scheduled to be in Washington just two more weeks. The Senate will return from its Thanksgiving recess next week but is scheduled to stay for most of the month. But with only one overlapping week, time is short.
Lawmakers and aides from both parties say a modest budget deal is possible that would set spending levels for the next two years and alleviate some automatic cuts by shifting savings to other parts of the government while raising some fees, such as those paid by airlines to fund the Transportation Security Administration.
To get the deal, Democrats have shelved demands for broader tax increases to pay for infrastructure and early-childhood education programs, and Republicans have dropped their push to restructure major programs like Medicare.
''It's not going to be anything earth-shattering,'' said Mr. Ribble, a House Budget Committee member briefed on the talks, ''but just operating under a budget so we can do our appropriations bills would be a quantum leap forward.''
The farm bill is a more difficult lift. House Republicans continue to press for $40 billion in cuts to the Supplemental Nutrition Assistance Program, or food stamps, while Senate negotiators are sticking to their $4 billion in cuts.
At the same time, it is an issue Republican constituents care about. Representative Tim Griffin of Arkansas said he got an email on Monday from his neighbor across the street saying her father cares nothing about politics but wants to know the farm bill's prospects.
But Democrats are digging in, putting Republican leaders between the demands of their Tea Party wing and the bipartisan clamor for a deal without deep cuts.
''If they want my vote, they ought to stop beating up on poor people,'' Mr. McGovern said. ''I don't think it's too much to ask to have a farm bill that doesn't increase hunger in America.''
URL: http://www.nytimes.com/2013/12/03/us/politics/least-productive-congress-on-record-appears-in-no-hurry-to-produce.html
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GRAPHIC: PHOTO: Representatives Paul D. Ryan and Bill Shuster met Monday with other committee leaders in Speaker John A. Boehner's office. (PHOTOGRAPH BY GABRIELLA DEMCZUK/THE NEW YORK TIMES)
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June 28, 2016 Tuesday 00:00 EST
Latest Plan to Cut Medicare Drug Payments Leaves Senators Skeptical
BYLINE: ROBERT PEAR
SECTION: US
LENGTH: 928 words
HIGHLIGHT: A federal health official promised to try to prevent harm to patients, but cited significant out-of-pocket costs for many patients under the status quo.
WASHINGTON - Under fire from senators in both parties, a senior federal health official told Congress on Tuesday that the Obama administration would adjust its plan to reduce Medicare payments for many prescription drugs, but those assurances did not fully allay deep concerns.
The official, Dr. Patrick H. Conway, a deputy administrator of the Centers for Medicare and Medicaid Services, indicated to the Senate Finance Committee that the administration would probably go ahead with its proposal in some form, and he promised that officials would try to prevent any harm to patients.
That did little to calm bipartisan fears. Senator Charles E. Grassley, Republican of Iowa, called the administration plan "an ill-conceived experiment" and suggested that it was a form of "human subjects research" for which the government needed the consent of patients.
Senator Ron Wyden of Oregon, the committee's senior Democrat, said he worried that the proposal "could unintentionally drive seniors toward hospitals," where treatment is typically more costly and less convenient.
That left Senator Tim Scott, Republican of South Carolina, to quip that the administration had done a good job bringing Republicans and Democrats together, with both parties hearing from constituents who fear that the cuts in Medicare payments could limit access to treatments.
The concerns may be understandable, with drug prices rising and seniors growing anxious, but Dr. Conway said the status quo was unsatisfactory. Patients are often responsible for 20 percent of the cost of extremely expensive medicines under Part B of Medicare, which covers outpatient services. In these cases, he said, patients "may face significant out-of-pocket expenses."
In its proposal, the administration wants to change reimbursement formulas to try to encourage doctors to choose lower-cost therapies. The administration said it wanted to require "mandatory participation" for doctors and hospitals that provide Part B drugs to Medicare beneficiaries in three-fourths of the nation's 7,000 "primary care service areas," using reimbursement formulas different from those in the federal Medicare law.
For a test, said Senator Patrick J. Toomey, Republican of Pennsylvania, that "seems almost universal." Senator Debbie Stabenow, Democrat of Michigan, agreed.
"The scope of the current proposal seems broader than is typical of demonstration projects," she said.
The test is to be conducted under a section of the Affordable Care Act that allows the secretary of health and human services to waive requirements of the Medicare law when trying out new payment models for a specific "defined population."
The administration plan goes far beyond such a demonstration project, Mr. Toomey said.
Under the proposal, Medicare might set a standard payment rate for a group of "therapeutically similar drug products," or pay less for an expensive drug where a less costly alternative was available.
However, cancer specialists say that for some treatments, no low-cost alternatives are available.
The administration could address some of the concerns by reducing the scope of its test, or by making it easier for doctors and patients to obtain exceptions to Medicare's "value-pricing policy."
While Dr. Conway said the administration would make adjustments in the final rule, he refused to be pinned down on specifics. When asked by a Democrat why the administration had proposed "such a large, expansive demonstration," Dr. Conway said, "You have to have a sufficiently large sample so that you can evaluate the model."
Part B drugs are often administered in doctors' offices or hospital outpatient departments.
Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee, said that many doctors, especially those in rural areas and small medical groups, could lose money buying drugs under the administration's proposal. If they no longer provide the drugs, he said, patients might have to travel to hospital clinics to get the infusions and injections.
In a separate action, the Obama administration on Tuesday unveiled a pilot program to speed the review of patent applications for drugs that mobilize the body's immune system to fight cancer. Such immunotherapies are among the most expensive medicines approved for sale in recent years, with annual costs exceeding $100,000 in some cases, but they have also shown great promise, scientists say.
In a notice to be published Wednesday in the Federal Register, Michelle K. Lee, the director of the United States Patent and Trademark Office, said her agency would expedite the review of immunotherapies that "destroy cancerous cells" or prevent their growth. To qualify for this special status, drug makers must be conducting clinical trials of the new treatments.
Ms. Lee, who is also an under secretary of commerce, said the pilot program was meant to advance the cancer "moonshot" initiative led by Vice President Joseph R. Biden Jr.
In the last year, dozens of cancer specialists have complained of exorbitant prices for drugs, including some that seem miraculous and others that extend lives by only a few months. Many of the drugs are covered under Part B of Medicare.
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House Republicans Unveil Long-Awaited Replacement for Health Law
Proposal to Reduce Medicare Drug Payments Is Widely Criticized
House Challenge to Health Law Could Raise Premiums, Administration Says
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December 21, 2013 Saturday
Late Edition - Final
New Health Law Frustrates Many in Middle Class
BYLINE: By KATIE THOMAS, REED ABELSON and JO CRAVEN McGINTY
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1258 words
Ginger Chapman and her husband, Doug, are sitting on the health care cliff.
The cheapest insurance plan they can find through the new federal marketplace in New Hampshire will cost their family of four about $1,000 a month, 12 percent of their annual income of around $100,000 and more than they have ever paid before.
Even more striking, for the Chapmans, is this fact: If they made just a few thousand dollars less a year -- below $94,200 -- their costs would be cut in half, because a family like theirs could qualify for federal subsidies.
The Chapmans acknowledge that they are better off than many people, but they represent a little-understood reality of the Affordable Care Act. While the act clearly benefits those at the low end of the income scale -- and rich people can continue to afford even the most generous plans -- people like the Chapmans are caught in the uncomfortable middle: not poor enough for help, but not rich enough to be indifferent to cost.
''We are just right over that line,'' said Ms. Chapman, who is 54 and does administrative work for a small wealth management firm. Because their plan is being canceled, she is looking for new coverage for her family, which includes Mr. Chapman, 55, a retired fireman who works on a friend's farm, and her two sons. ''That's an insane amount of money,'' she said of their new premium. ''How are you supposed to pay that?''
An analysis by The New York Times shows the cost of premiums for people who just miss qualifying for subsidies varies widely across the country and rises rapidly for people in their 50s and 60s. In some places, prices can quickly approach 20 percent of a person's income.
Experts consider health insurance unaffordable once it exceeds 10 percent of annual income. By that measure, a 50-year-old making $50,000 a year, or just above the qualifying limit for assistance, would find the cheapest available plan to be unaffordable in more than 170 counties around the country, ranging from Anchorage to Jackson, Miss.
A 60-year-old living in Polk County, in northwestern Wisconsin, and earning $50,000 a year, for example, would have to spend more than 19 percent of his income, or $9,801 annually, to buy one of the cheapest plans available there. A person earning $45,000 would qualify for subsidies and would pay about 5 percent of his income, or $2,228, for an inexpensive plan.
In Oklahoma City, a 60-year-old earning $50,000 could buy one of the cheapest plans for about 6.6 percent of his income, or about $3,279 a year with no subsidy. If he earned $45,000, with the benefit of a subsidy, he would spend about $2,425.
While the number of people who just miss qualifying for subsidies is unclear, many of them have made their frustration known, helping fuel criticism of the law in recent weeks. Like the Chapmans, hundreds of thousands of people have received notices that their existing plans are being canceled and that they must now pay more for new coverage.
In an effort to address that frustration, the Obama administration announced on Thursday that it would permit people whose plans had been canceled to buy bare-bones catastrophic plans, which are less expensive but offer minimal coverage. Those plans have always been available to people under 30 and to those who can prove that the least expensive plan in their area is not affordable. But the announcement does not address the concerns of those who would like to buy better coverage, yet find premiums in their area too expensive.
David Oscar, an insurance broker in New Jersey, another high-cost state, said many of his clients had been disappointed to learn that the premiums were much more expensive than they had expected.
''They're frustrated,'' he said. ''Everybody was thinking that Obamacare was going to come in with more affordable rates. Well, they're not more affordable.''
Many of the biggest provisions of the Affordable Care Act are aimed squarely at the poorest of Americans. Under the law, states have the option of expanding Medicaid to a larger pool of people with the lowest incomes. To those earning more, the law provides subsidies to people earning up to four times the federal poverty level, or $45,960 for an individual and $62,040 for a couple.
Ninety percent of the country's uninsured population have incomes that fall below that level, according to one recent analysis. As a result, the subsidies ''are well targeted for people who are uninsured or underinsured,'' said Sara R. Collins, an executive with the Commonwealth Fund, a private foundation that finances health policy research. ''That is really where the firepower of the law is focused.''
Federal assistance is based on the cost of premiums for the second-cheapest silver, or midlevel, plan in a person's geographic area and are set so the amount the person must pay for coverage does not exceed a certain percentage of income, ranging from 2 to 9.5 percent.
Even before the announcement on Thursday giving people with canceled plans the option of buying catastrophic coverage, the law permitted people to select such plans if the price of premiums in their area exceeded 8 percent of their income. The catastrophic plans are often less expensive and include three doctor visits and free preventive care, but require someone to pay almost all of the medical bills up to a certain amount, which is usually several thousand dollars.
That is the option that the Chapmans say they are likely to choose when their current insurance plan, which costs $665 a month, expires in September. Anthem is the only insurer offering plans in the marketplace in New Hampshire, and prices there are higher than in many other parts of the country.
Some experts dismissed the varying effects of the income cutoff, saying the law's main elements benefit most of those who could not previously buy insurance.
''I think that job one was to make sure that the people who clearly have the greatest difficulty affording premiums receive the greatest help,'' said Ron Pollack, the founding executive director of Families USA, a consumer advocacy group that favored the law.
To avoid creating such steep cliffs, federal officials would have had to spend more money on the subsidies, said Larry Levitt, an executive with the Kaiser Family Foundation, a nonprofit research group that is closely following the health care law. Subsidies would have been higher, and could have been more gradually phased out, he said. The design ''was largely driven by budgetary decisions,'' Mr. Levitt said.
The subsidy cutoff can seem especially arbitrary to people whose incomes vary from year to year, even if they stand to benefit from the law.
Christian Johnsen, a bakery owner who lives with his wife and two children in Big Sky, Mont., and has an income of about $88,000, will probably be eligible for subsidies next year. As a result, the family could buy a midlevel insurance plan for about $697 a month.
But if the bakery does better next year, the family could be asked to pay a lot more. Without any subsidy, the same plan would cost $822.
Mr. Johnsen, who is 47, said he would like to buy insurance for his family. They have gone without it for the last two years, paying out of pocket on rare visits to the doctor. But he said it is hard to justify those prices to prevent an unforeseen catastrophe when so many real-world expenses demand his attention first.
''I know absolutely that I'm going to need a new car in two years, but I don't know that I'm going to have a catastrophic accident,'' he said. ''That's the kind of debate that happens in our house.''
URL: http://www.nytimes.com/2013/12/21/business/new-health-law-frustrates-many-in-middle-class.html
LOAD-DATE: December 21, 2013
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GRAPHIC: PHOTO: Doug and Ginger Chapman with their son Charlie Galanes, 11. They are looking for new coverage after their plan was canceled. (PHOTOGRAPH BY HERB SWANSON FOR THE NEW YORK TIMES) (B7) CHARTS: A Steep Financial Cliff for Older Consumers: The Affordable Care Act provides subsidies for health insurance to individuals making up to four times the federal poverty level, or $45,960. But anyone making just over that line may have to pay thousands of dollars more for the same plan. (Sources: New York Times analysis of data from the Department of Health and Human Services, Kaiser Family Foundation and state exchanges) (B7)
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November 27, 2014 Thursday
Late Edition - Final
Wyoming Devises Plan to Expand Medicaid
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 26
LENGTH: 489 words
WASHINGTON -- With a plan released Wednesday by the administration of Gov. Matt Mead, a Republican, Wyoming has become the latest state seeking to expand Medicaid.
The plan would provide Medicaid coverage to an additional 18,000 low-income people, according to the state's health department. If it wins federal and state legislative approval, Wyoming will join 27 states that have expanded the program under the Affordable Care Act, including nine with Republican leadership.
As several other Republican governors have done, Mr. Mead wants to require some people who receive coverage under the expansion to pay something toward the cost. Under his plan, those earning 100 to 138 percent of the federal poverty level -- for a single person, $11,670 to $16,105 a year -- would have to pay monthly premiums. The premiums could range from about $20 to $50 a month, depending on household size and income, according to a summary of the plan.
The Obama administration has to sign off on the plan because it deviates from regular Medicaid expansion under the federal health care law.
People earning less than 100 percent of the poverty level would not have to pay monthly premiums. But they could owe small co-payments for certain services, as could the higher-income group. Those deemed ''medically frail'' would get Medicaid, which has a slightly more comprehensive benefits package, said Kim Deti, a spokeswoman for the Wyoming Department of Health.
The expansion plan would also require approval from the State Legislature, which is controlled by Republicans. If lawmakers approve the plan, it will most likely take effect in 2016. The Legislature has already rejected several bills that would have expanded traditional Medicaid. But earlier this year it authorized Mr. Mead to negotiate with the Obama administration on a modified version.
''We have done the work and we have a plan,'' Mr. Mead said in a statement. ''I believe it is the most favorable plan for Wyoming, and it addresses the needs of those who fall in the gap.''
Wyoming officials considered the ''private option'' alternative that Arkansas adopted, which uses federal Medicaid expansion funds to buy private coverage for low-income residents through the state's health insurance exchange. But they decided it would cost too much, according to a report detailing the proposal, because exchange plans in Wyoming are among the most expensive in the nation.
Under the terms of the Affordable Care Act, the federal government pays the entire cost of Medicaid expansion through 2015, and at least 90 percent of the cost in later years. The Wyoming plan includes a provision that would terminate Medicaid expansion there if the federal share ever dropped below 90 percent.
At least three other Republican governors -- Mike Pence of Indiana, Bill Haslam of Tennessee and Gary R. Herbert of Utah -- are negotiating with the federal government on alternative forms of Medicaid expansion.
URL: http://www.nytimes.com/2014/11/27/us/wyoming-devises-plan-to-expand-medicaid.html
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January 1, 2017 Sunday 00:00 EST
With New Congress Poised to Convene, Obama's Policies Are in Peril
BYLINE: JENNIFER STEINHAUER
SECTION: US; politics
LENGTH: 1370 words
HIGHLIGHT: The most powerful and ambitious Republican-led Congress in 20 years plans quick action on several priorities - most notably to clear a path for the repeal of President Obama's health care law.
WASHINGTON - The most powerful and ambitious Republican-led Congress in 20 years will convene Tuesday, with plans to leave its mark on virtually every facet of American life - refashioning the country's social safety net, wiping out scores of labor and environmental regulations and unraveling some of the most significant policy prescriptions put forward by the Obama administration.
Even before President-elect Donald J. Trump is sworn in on Jan. 20, giving their party full control of the government, Republicans plan quick action on several of their top priorities - most notably a measure to clear a path for the Affordable Care Act's repeal. Perhaps the first thing that will happen in the new Congress is the push for deregulation. Also up early: filling a long-vacant Supreme Court seat, which is sure to set off a pitched showdown, and starting confirmation hearings for Mr. Trump's cabinet nominees.
"It's a big job to actually have responsibility and produce results," said Senator Mitch McConnell of Kentucky, the majority leader. "And we intend to do it."
But as Republicans plan to reserve the first 100 days of Congress for their more partisan goals, Democrats are preparing roadblocks. The party's brutal election-year wounds have been salted by evidence of Russian election interference, Mr. Trump's hard-line cabinet picks and his taunting Twitter posts. (On Saturday, he offered New Year's wishes "to all," including "those who have fought me and lost so badly they just don't know what to do.")
Obstacles will also come from Republicans, who are divided on how to proceed with the health care law and a pledge to rewrite the tax code. Some are also skittish about certain policy proposals, like vast changes to Medicare, that could prove unpopular among the broad electorate. And any burst of legislative action will come only if Congress can break free of its longstanding tendency toward gridlock.
For Republicans, the path to this moment has been long and transparently paved - the House in particular has signaled the Republican policy vision through bills it has been passing for years. But many of those measures have gathered dust in the Senate or been doused in veto ink.
The cleft between the two chambers recalls the situation faced by the insurgent House Republican majority in the mid-1990s. Speaker Newt Gingrich took control with a determined agenda, only to be stymied by the Senate majority leader, Bob Dole, who stacked conservative House bills like so many fire logs in the back of the Senate chamber.
"They've been given a golden opportunity here," said Trent Lott, the former Republican Senate majority leader. "But I have watched over the years when one party has had control of the White House and the Senate and the House, and the danger is overplaying your hand.
"If you go too far, like what happened with Obamacare, and you get no support at all from the other side, you have a problem," Mr. Lott continued. "You have to find a way to work with people across the aisle who will work with you."
The tax overhaul and an infrastructure bill may be two opportunities for bipartisan cooperation; the Senate Finance Committee is already moving in that direction. Still, both of those issues are expected to remain on the back burner, despite promises to the contrary from Mr. Trump's chief of staff, Reince Priebus.
The Senate may be narrowly divided, but among the 48 senators in the Democratic caucus are 10 who will stand for re-election in two years in states that voted for Mr. Trump. Republicans are counting on their support, at least some of the time.
But on many issues, Senate Democrats - including their new leader, Chuck Schumer of New York - are expected to pivot from postelection carping to active thwarting, using complex Senate procedures and political messaging to slow or perhaps block elements of Mr. Trump's agenda.
"After campaigning on a promise to help the middle class, President-elect Trump's postelection actions suggest he intends to do the exact opposite after he's sworn in," said Senator Patty Murray, Democrat of Washington. "Democrats will do everything we can to fight back if he continues to pursue an agenda prioritizing billionaires and big corporations while devastating middle-class families and the economy."
Republicans have chafed for years at a host of rules, many business-related, that President Obama has issued through the regulatory process, and they have been advising the Trump team on which ones should be undone.
"I hear probably more about the strangulation of regulations on business and their growth and their development than probably anything else," the House speaker, Paul D. Ryan of Wisconsin, said at a recent forum. "I think if we can provide regulatory relief right away, that can breathe a sigh of relief into the economy."
In late December, the Obama administration rolled out a major new environmental regulation intended to rein in mountaintop-removal mining. That regulation, one of dozens that Mr. Trump is expected to reverse, is meant to go into effect one day before his inauguration.
But Congress is likely to block it, using the obscure Congressional Review Act, which permits lawmakers to undo new regulations with only 51 Senate votes within the first 60 legislative days of the rules' completion.
Given time constraints on the Senate floor, members will have to pick some priorities. They are expected to train their sights on a rule that requires oil and gas producers to reduce methane gases, another that requires mining and fossil fuel companies to disclose payments they have made to foreign governments to extract natural resources, and still others that restrict pesticide use.
Republicans will also move quickly to repeal the Affordable Care Act. They plan to pass a truncated budget resolution for the remainder of the fiscal year - already a quarter over - that includes special instructions ensuring that the final repeal legislation could circumvent any Democratic filibuster. But Republican leaders have not settled on a health care plan to replace Mr. Obama's, and they may delay the repeal measure's effective date for years.
The Senate must also consider Mr. Trump's cabinet picks, and Senate Democrats are already trying to slow the process. However, they cannot do much more than that, because when they were in charge, they changed the rules so that presidential nominees other than Supreme Court picks need only 51 votes to be confirmed. Previously, such nominations could face a filibuster, which required 60 votes to overcome.
Democratic leaders have encouraged members to avoid meeting with Mr. Trump's nominees until they have turned over their tax returns and made other disclosures. Republicans have been particularly upset that Senator Jeff Sessions of Alabama, whom Mr. Trump picked quickly to be attorney general, has either not gotten meetings with Democrats on the Senate Judiciary Committee or had meetings canceled.
Senator Dianne Feinstein of California postponed her meeting with Mr. Sessions until January because, she said, her schedule got too busy. "The senator doesn't want to rush," said her spokesman, Tom Mentzer.
One reason that Democrats are in no hurry is their bitterness over Mr. McConnell's refusal last year to hold a hearing on the Supreme Court nomination of Judge Merrick B. Garland.
Lingering in the background is the specter of Russia. Democrats - and some Republicans, who are at odds with Mr. Trump on the issue and may at times be a brake on him - want a vigorous investigation of its efforts to disrupt the election. The Obama administration, which took sweeping steps last week to punish the Russians over election hacking, will release a report this month that is likely to serve as a turning point in those discussions.
While Republicans may have a rare chance to open the flow of legislation, the party's leaders are acutely aware of the punishment that Americans have historically delivered in midterm elections when things have not gone well.
"This is no time for hubris," Mr. McConnell said. "You have to perform."
PHOTO: Senator Mitch McConnell of Kentucky, the majority leader. Congress will convene on Tuesday. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES) (A9)
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March 26, 2013 Tuesday
Bakery Owner Talks About Coping With Health Insurance Changes
BYLINE: JULIE WEED
SECTION: BUSINESS; smallbusiness
LENGTH: 923 words
HIGHLIGHT: Rachel Shein, owner of Baked in the Sun, responds to reader comments from last week’s case study.
Last week, we published a case study about Baked in the Sun, a wholesale bakery and distributor that is trying to decide how best to comply with the Affordable Care Act. Starting in January, the new law requires businesses with 50 or more full-time employees to offer health insurance or pay a penalty. Owned by Rachel Shein and Steve Pilarski, husband and wife, the company employs nearly 100 workers to bake and deliver freshly made pastries to coffee shops, hospitals and hotels in Southern California.
Baked in the Sun has offered health insurance to its employees in the past but many are young and healthy and have preferred to keep more money in their paycheck, rather than contribute to a health plan. Soon, though, almost all workers will have to carry health insurance - through their employer, a government exchange or other source - or pay a penalty. And, as the case study discussed, Ms. Shein and Mr. Pilaski are trying to decide whether they will offer health insurance, pay a penalty or outsource enough work that they can reduce their head count below 50 and be exempt from the law.
The article elicited lots of comments and strong opinions, as well as reports in other media outlets, including CNBC, which included Ms. Shein in a panel discussion about her company's situation. Some readers argued that Baked in the Sun has a moral obligation to offer coverage. Others argued for a single-payer system that would allow owners to stop worrying about health insurance and focus on running their businesses.
Andrew Greenblatt, a senior vice president at Benestream, which helps low wage employees apply for government benefits, pointed out that under the Affordable Care Act, Medicaid has been expanded to cover families earning up to 138 percent of the poverty level, which means that workers who make minimum wage, especially single parents, may qualify.
And Alan Cohen, chief strategy officer for Liazon, a private insurance exchange for companies, suggested in a comment that many employees will be better off if the bakery chooses not to offer insurance and instead pays the government penalty. That's because the employees would be likely to qualify for a subsidy at a government exchange that would allow them to insure their whole family - but only if their employer does not offer health insurance.
Of course, because neither the minimum level of coverage, nor the costs to all the insurance options have been finalized, lots of uncertainty remains. We contacted Ms. Shein for a follow-up conversation that has been condensed and edited.
Q.
A number of readers suspect that you are underestimating how much it would actually cost to insure your employees. Have you taken another look?
A.
The insurance plans are still under development. My broker recently found one that was less than what I had found, but I'm not sure anyone knows what the final rules and prices will be.
Q.
Have you thought any further about how many of your employees will actually sign up for insurance if you offer it?
A.
In the short run, when the individual penalty is low, there might not be much participation. We plan to have a meeting with our employees to see what kind of insurance they might want and which of them might be covered elsewhere.
Q.
Did this discussion have any impact on your thinking about whether you will pay the penalty or offer insurance?
A.
The employees will all have access to health insurance whether we provide it, or we pay the penalty and they purchase it using a subsidy on the government exchange. We need to look at all the costs and tax implications and do whichever is least expensive for the business.
Q.
Are there any reader questions you want to answer?
A.
Some readers claimed it was a moral imperative to provide insurance - but all employees will have insurance under the law.
Q.
Some readers thought your profit margin was too low and questioned how well your business was doing. What was your reaction?
A.
Like many entrepreneurs we have great years where we can take vacations and put money into our kids' college funds. Some years are leaner.
Q.
Do you think your customers would pay a few more cents for your baked goods - especially if it allows you to offer your employees health insurance?
A.
Our products are unbranded and sold in hundreds of outlets so it would be hard to educate consumers about our employment practices. And the popularity of Wal-Mart shows that most consumers just want the best price.
Q.
You suggested in the article that you might have to raise your prices 4 percent to cover the cost of providing health insurance. But 4 percent of $8 million - your annual revenue - is $320,000. That's a lot more than you estimated the cost of insurance. Couldn't you just raise your prices 2 percent?
A.
Yes, a 2- to 3-percent increase could cover the costs, but it's a low margin business and pennies matter so we like to build in some buffer.
Q.
Would you favor a single-payer system?
A.
I am in favor of a system that doesn't penalize a business for being successful and able to hire more than 50 people and doesn't deter us from wanting to grow. I am in favor of a system where everyone pays in, and everyone is covered. If that is a single-payer system, I'm for that.
Should a Bakery With More Than 50 Employees Offer Health Insurance?
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How Did You Get So Lucky With Renewal Rates?
For Business Owners, the Health Care Details Begin to Emerge
Assessing the Impact of Health Care Reform on New Businesses In Massachusetts
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May 1, 2013 Wednesday
Shorter Forms for Coverage Under New Health Law
BYLINE: ANN CARRNS
SECTION: YOUR-MONEY
LENGTH: 360 words
HIGHLIGHT: Earlier versions of the forms to apply for coverage under the new health law ran to 21 pages.
Banks and mortgage lenders have made strides in simplifying their disclosure forms so consumers can more easily understand the types of fees and terms they are getting.
Now, the federal health officials are trying to shrink the amount of paper necessary for people to apply for coverage under the new health insurance marketplaces, or exchanges, that are to begin operating this fall. The exchanges are part of the Affordable Care Act.
The first version of the form from the Centers for Medicare and Medicaid Services was a 21-page monster that would have taken an estimated 45 minutes to complete.
This week, after consumer advocates warned that the form was too overwhelming for most people, the government unveiled shorter versions. The form for individuals who aren't offered insurance by their employer is now three pages, while the form for familiesis 12 pages.
"The shorter, just the facts applications will help empower consumers to make the health care decisions that are right for them, their families and their budget," Anne Filipic, president of Enroll America, said in a statement. The nonprofit group aims to educate consumers about the new law and help them obtain coverage.
But Kaiser Health News questioned whether the forms were actually simpler, or just shorter. The form for families, for instance, previously had pages to list health information for six separate family members. Now, the news service says, the form just has space for two people. So if your family is larger, you'll have to make photocopies of the page for the additional members.
The forms can be submitted beginning Oct. 1, according to the agency. Consumers can fill out the application on paper, over the phone or online. The online version should take less time, according to the centers, because it will eliminate some questions based on the applicant's responses.
Do you plan to apply for coverage through the new marketplaces? What do you think of the new forms?
Breast Pump Coverage Under New Law Varies In Practice
Workers' Share of Health Costs Is Likely to Continue Rising
Visiting the Doctor, Virtually
What the Health Care Ruling Means for You
Decoding Your Medical Bill
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March 17, 2015 Tuesday
Late Edition - Final
House Republican Budget Overhauls Medicare and Repeals the Health Law
BYLINE: By JONATHAN WEISMAN
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 1108 words
WASHINGTON -- House Republicans on Tuesday will unveil a proposed budget for 2016 that partly privatizes Medicare, turns Medicaid into block grants to the states, repeals the Affordable Care Act and reaches balance in 10 years, challenging Republicans in Congress to make good on their promises to deeply cut federal spending.
The House proposal leans heavily on the policy prescriptions that Representative Paul D. Ryan of Wisconsin outlined when he was budget chairman, according to senior House Republican aides and members of Congress who were not authorized to speak in advance of the official release.
With the Senate now also in Republican hands, this year's proposal is more politically salient than in years past, especially for Republican senators facing re-election in Democratic or swing states like Pennsylvania, Wisconsin, Illinois and New Hampshire, and for potential Republican presidential candidates.
Mr. Ryan's successor, Representative Tom Price, Republican of Georgia, promised on Monday ''a plan to get Washington's fiscal house in order, promote a healthy economy, protect our nation and save and strengthen vital programs like Medicare.''
Democrats -- and those Republicans who support robust military spending -- will not see Mr. Price's ''Balanced Budget for a Stronger America'' in those terms. Opponents plan to hammer Republican priorities this week, as the House and Senate budget committees officially begin drafting their plans on Wednesday, and then try to pass them through their chambers this month.
On Monday, President Obama tried to get ahead of the debate by criticizing Republican plans to abide by strict domestic and military spending caps.
''I can tell you that if the budget maintains sequester-level funding, then we would actually be spending less on pre-K to 12th grade in America's schools in terms of federal support than we were back in 2000,'' the president said in a speech to the Council of the Great City Schools. ''The notion that we would be going backward instead of forwards in how we're devoting resources to educating our kids makes absolutely no sense.''
But Republican aides said they have weathered those attacks ever since Mr. Ryan released his first budget plan in 2011. They said the easiest way to prevail in the House, at least, is to put forward the budget plan most House members have voted on multiple times.
''We've had House people vote on these four years in a row. We've held on to our majority and even expanded it,'' said Representative Tom Cole, Republican of Oklahoma and a Budget Committee member. ''The idea you're going to lose an election on this is more political theater than political reality.''
Congressional budgets do not have the force of law and are largely advisory documents, but they represent the broadest statement of governing philosophy each year and set overall spending levels for the coming fiscal year. And in coming months, this one may contain language easing passage of taxation and entitlement legislation.
Under congressional rules, a budget cannot be filibustered in the Senate, so Republicans would bear most of the responsibility if they failed to pass one.
House Budget Committee members previewed their plans in an unusual, campaign-style video on Monday. The plan envisions a remaking of the federal government. Future recipients of Medicare would be offered voucherlike ''premium support'' to pay for private insurance rather than government-provided health care.
Spending on Medicaid would be cut substantially over 10 years, with the money turned into block grants to state governments, which in turn would have much more flexibility in deciding how it is allocated.
The budget ''repeals all of Obamacare,'' Representative Diane Black, Republican of Tennessee, said the same day the Obama administration announced that the law had provided coverage to 16.4 million previously uninsured people.
To placate advocates of the military who say strict budget caps are hurting national defense, the House budget adds ''emergency'' war spending through the ''overseas contingency operations'' account, which does not count against the spending limits.
The budget will also include language that orders members of the tax-writing Ways and Means Committee to draft a ''fairer, simpler tax code,'' said Representative Todd Rokita, Republican of Indiana.
And it will include parliamentary language -- called ''reconciliation'' -- aimed at allowing legislation to repeal the Affordable Care Act to pass the Senate with a simple majority. If that bill is passed, it will still be subject to a presidential veto.
Conservative groups insist Republicans must keep their promise and repeal the Affordable Care Act.
''Republicans owe their majorities to their unwavering opposition to Obamacare, a reality that must be reflected in the budget,'' declared Heritage Action, the political arm of the conservative Heritage Foundation. ''A throwaway line that the budget 'repeals Obamacare in its entirety' is not enough.''
House Republicans conceded on Monday that the Senate was not likely to propose such extensive cuts. Even before the Senate plan is unveiled, deep rifts are appearing. Senator John McCain of Arizona, chairman of the Senate Armed Services Committee, reiterated his demand on Monday that any budget raise military spending well above the statutory caps. And he said he would not accept an approach that raised spending through the war-fighting emergency account or by shifting money from already squeezed domestic programs.
Last year, Mr. Ryan called ''emergency spending'' increases ''a backdoor loophole that undermines the integrity of the budget process.''
Republican leaders worry that the Republican senators making moves to run for president -- Ted Cruz of Texas, Rand Paul of Kentucky, Marco Rubio of Florida and Lindsey Graham of South Carolina -- will never find a budget to their liking. At the same time, Republican senators from Democratic states, such as Mark S. Kirk of Illinois, will be hard-pressed to agree to the House's conservative vision.
In 2013, when the Senate was presented an amendment to prohibit replacing Medicare's guaranteed benefits ''with the House passed budget plan to turn Medicare into a voucher program,'' 96 senators agreed. Only three, Mr. Cruz, Mr. Paul and Senator Mike Lee, Republican of Utah, supported the House's vision.
''Historically, the Senate has been less willing to take on the tough issues, and the early sounds are they're not going to do a Ryan-type Medicare-Medicaid plan,'' Mr. Cole said. ''They face a very difficult election atmosphere next year.''
URL: http://www.nytimes.com/2015/03/17/us/politics/house-republican-budget-overhauls-medicare-and-repeals-the-health-law.html
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